Dangerous Assumptions Residents Make About ‘Chronic’ Chest Pain at Night

It is 2:37 a.m. You just sat down after admitting a decompensated cirrhotic, your pager has not been quiet for three minutes straight, and now the nurse calls:

“Hey, your patient in 4B is having chest pain. She says it is the same chronic chest pain she has every night. She just wants something to help her sleep.”

You are exhausted. Your brain immediately reaches for the relief valve: chronic, same as usual, nighttime, anxious patient. You are tempted to say the most dangerous words in overnight medicine:

“If it is her usual chronic pain, just give her what she gets at home.”

Do not do this. This is exactly where residents get burned.

This is an article about the lethal comfort of that word: chronic.

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The Single Most Dangerous Assumption: “Chronic = Benign”

Let me be blunt: chronic chest pain kills people all the time. The problem is not the pain. It is the change hidden inside a story that sounds routine.

The assumption:

“She has had this for years, it is the same thing. It cannot be an acute coronary syndrome.”

Wrong. I have watched charts where the first note said “chronic atypical chest pain, same as usual,” and the next morning the patient was in the cath lab with a troponin of 15. I have also seen the chart that turned into a mortality review.

Here is what residents get wrong when they hear “chronic”:

• They stop asking what is different tonight.
• They anchor on the old diagnosis (GERD, anxiety, musculoskeletal pain).
• They accept the patient’s label (“it is just my reflux”) without questioning it.
• They shortcut the workup because it is 3 a.m. and they are drowning.

You must fight that reflex.

The real rule

If a patient with chronic chest pain is in the hospital and has any of the following, you treat tonight’s pain as new until proven otherwise:

• Different quality, location, or radiation
• Different intensity or pattern
• New associated symptoms (dyspnea, diaphoresis, presyncope, nausea, palpitations)
• New triggers (minimal exertion, occurring at rest, waking from sleep)
• Higher risk context (post-op, new arrhythmia, sepsis, major anemia, recent cocaine use)

Chronic does not mean safe. Chronic just means it has been there long enough for you to be complacent.

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Anchoring on Old Labels: “It’s Just Their GERD / Anxiety / Musculoskeletal Pain”

This one is a classic and it is subtle. You see in the chart:

• “Seen multiple times in ED for chest pain”
• “Normal coronaries 2 years ago”
• “Hx of GERD / panic attacks”
• “Musculoskeletal chest wall pain – reproducible”

Your brain whispers: “Oh good. This is the same frequent flyer chest pain. Low risk.”

You are about to make a mistake.

Why the comfort of prior workups is false

• Normal stress test 1–2 years ago: does not rule out new plaque rupture, vasospasm, or in-stent thrombosis.
• Clean coronaries years ago: people develop CAD over time. Diabetes, CKD, chemo, radiation, and smoking accelerate that.
• Prior diagnosis of GERD: retrosternal burning that responds to antacids does not exclude concomitant ischemia later.
• Anxiety disorder: patients with anxiety can also have MI. The “panic attack” label lets ischemia hide in plain sight.
• “Reproducible chest pain”: yes, musculoskeletal pain exists, but reproducible tenderness does not exclude ACS. That old trope needs to die.

The worst combo I see:
“40-something woman, labelled anxiety + GERD, recurring nocturnal chest pain, always given a GI cocktail.” Some of them have real ischemia. Some get missed.

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The Nighttime Trap: “If It Happens Every Night, It Cannot Be ACS”

Night shifts train you to look for shortcuts. One of the laziest ones: assuming circadian pattern = benign.

You hear: “The pain always comes at night / every time I am trying to sleep.” So you think:

• Acid reflux when lying flat
• Anxiety when trying to sleep
• Musculoskeletal pain after a long day

All plausible. But there are real pathologies with nighttime patterns too:

• Nocturnal angina – reduced sympathetic tone, lower BP, and coronary vasospasm can provoke symptoms at rest.
• Variant (Prinzmetal) angina – often occurs at rest, overnight, or early morning, with transient ST elevations.
• Decompensating heart failure – orthopnea and chest tightness when lying flat get mis-labeled as “anxiety at night.”
• Obstructive sleep apnea – surges of hypertension and hypoxia at night destabilize plaques.
• Hypertensive emergencies – many patients note headaches or chest pressure on awakening or at night.

So that story of “It always happens at night when I am in bed” is not a free pass. It is actually a red flag to listen more carefully.

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The “They’re Young / Thin / Female / Non-Cardiac” Bias

You will not admit this bias out loud. But you will feel it.

• The 34-year-old woman with “chronic costochondritis”
• The 29-year-old man with anxiety and weed use
• The 45-year-old non-smoking vegetarian with “GERD”

You downshift your concern. You shortcut the evaluation. You let their demographics talk you out of a full assessment.

Here is the problem: atypical demographics are exactly where people get missed.

• Young women with MI are consistently undertreated and underdiagnosed.
• Diabetes, lupus, rheumatoid arthritis, HIV, CKD, or chemotherapy history destroy your age-based reassurance.
• Cocaine, meth, or even heavy stimulant use can precipitate vasospasm or MI in 20-somethings.

If you catch yourself thinking, “They are way too young for real CAD”—stop. That thought has been in the first paragraph of many malpractice complaints.

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Ignoring Subtle Change: When “Same As Usual” Is a Lie

Sometimes patients minimize. Sometimes they genuinely cannot tell you what is different. Sometimes they are terrified of “bothering” staff at night.

You cannot just accept “same as usual” at face value.

The right move at 3 a.m.

When you get that “chronic chest pain” call:

1. Ask specific comparison questions
   Not “Is it the same?” Instead:

   • “On a scale of 1–10, what is the usual pain, what is it now?”
   • “Does it go anywhere else now that it did not before?”
   • “Any more shortness of breath / sweating / nausea this time?”
   • “Can you lie flat comfortably or does that make it worse?”
   • “Did anything trigger it tonight? Walking to the bathroom? Just lying still?”

2. Clarify timing and pattern

   • “How long did this episode last before you called?”
   • “Has this ever woken you from sleep before?”

3. Ask about context changes

   • New medication (especially beta-blockers, nitrates withdrawn, stimulant started)
   • Recent surgery, long travel, immobilization (think PE)
   • New infection, anemia, GI bleed, or hypotension

If anything feels “off,” that is your cue: this is not just chronic. This needs objective evaluation.

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Shortcutting the Minimum Workup: You Are Not Allowed to Be Blind

Here is the blunt rule for the hospital at night:

• If your name is going in the chart next to the words “chest pain,” and you do not at least look at an EKG, you are gambling with your license and your patient.

You do not need a massive cardiac workup at 3 a.m. for every vague discomfort. But I have seen residents rationalize themselves right past the basics.

The dangerous pattern

• Nurse calls for chest pain.
• Resident hears “chronic” and “same.”
• Resident orders:
  • PRN morphine or oxycodone
  • Trazodone or melatonin “to help them sleep”
  • Maalox or GI cocktail
• No:
  • EKG
  • Vital signs review (including new O2 requirement)
  • Focused exam
  • Brief chart review for risk factors

That is not being efficient. That is being reckless.

The defensible minimum for inpatients

If you are called for chest pain at night on the floor:

1. Check current vital signs
   Not from 6 hours ago. Now. Pay attention to:

   • New tachycardia
   • New hypotension or hypertension
   • New tachypnea
   • New hypoxia

2. Get an EKG

   • Baseline to compare to prior tracings
   • You will miss transient STEMIs and ischemia if you just “trust” old EKGs.

3. See the patient
   Yes, really walk there.

   • Assess appearance: distressed, diaphoretic, pale, very anxious?
   • Listen to lungs and heart. Look for JVD, edema, new murmurs.
   • Palpate chest wall but remember: tenderness does not rule out MI.

4. Decide about labs

   • If any concern at all: get at least one troponin and possibly serial if story is worrisome.
   • Check hemoglobin if risk for anemia/bleed.
   • Consider BMP if they are on diuretics, renally cleared meds, or have CHF.

You will not regret getting one “unnecessary” EKG at 3 a.m. You will absolutely regret skipping the one that would have showed evolving ischemia.

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Over-Reliance on Previous Negative Troponins, Stress Tests, or Caths

I see this all the time in signout:

"Chronic chest pain, had a normal stress two months ago, trops negative on last admission, low concern."

Then at 2 a.m., the patient has worse pain and you talk yourself out of re-checking.

Why old negatives do not protect you tonight

• Stress tests have false negatives, especially in women and in microvascular disease.
• A “normal cath” years ago is not a lifetime warranty.
• Troponins were negative yesterday because the infarct had not happened yet.
• Microvascular angina, vasospasm, and demand ischemia can present with normal coronaries.

Think of prior negative evaluations as “probability reducers,” not shields. They lower risk. They never bring it to zero.

When the story changes, all prior tests reset. You are dealing with a new event until you prove otherwise.

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Special Populations You Will Underestimate

You will get burned if you assume “chronic” and “non-specific” are safe in these groups:

Group	Why You Must Be Extra Careful
Women <50 with risk factors	Under-diagnosed, atypical symptoms
Diabetics	Silent or blunted ischemia
CKD/ESRD	Baseline ECG changes, atypical pain
Post-op (esp. ortho/abdominal)	High PE and MI risk
Cocaine/meth users	Vasospasm, MI at young ages

These are the patients where “I think it is just their usual pain” sounds very weak in hindsight.

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Sedation and Analgesia: Masking a Bad Story

One more trap: using sedatives and opioids as diagnostic tools.

• Giving IV morphine, seeing their chest pain improve, then declaring “non-cardiac.”
• Giving lorazepam, watching their anxiety and pain settle, and writing “panic attack.”

Response to treatment is not a diagnostic test. Opioids will often reduce any moderate pain. Benzos will calm anyone. You can convince yourself of whatever narrative you want after that.

The specific bad sequence

1. Resident gets call for “chronic chest pain.”
2. Orders:
   • IV morphine “for comfort”
   • 1 mg lorazepam “for anxiety”
3. Never gets an EKG or sees the patient.
4. Documents: “Chest pain improved with morphine, likely chronic non-cardiac pain.”

Later, that same patient declares STEMI or is found hypotensive and altered with a huge troponin.

Do not use narcotics and benzos to blind yourself. If the pain is bad enough to warrant IV opioids, it is bad enough to justify an EKG and eyes-on exam.

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When You Actually Can Call It “Chronic” Safely

You are not in residency to order CT-PEs and troponins on every twinge of discomfort. There are truly low-risk scenarios. The problem is knowing when you have earned that shortcut.

You can breathe a little easier when:

• The patient has:
  • An unchanged, long-standing pattern of pain
  • A recent, high-quality cardiac evaluation
  • No new associated symptoms or red flags
• Tonight’s pain:
  • Is completely identical in quality, location, triggers, and relief
  • Occurs in a low-risk context (no new hypotension, infection, bleeding, surgery)
  • Resolves fully with conservative measures you have used before
• And you have:
  • Personally seen the patient
  • Reviewed vital signs and at least one EKG in this admission
  • Documented clearly why you think this is unchanged chronic pain

Then, and only then, you can reasonably say, “This is chronic, and tonight is truly nothing new.” But do not let “chronic” be the starting assumption. It should be the conclusion after a minimal evaluation.

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A Simple Mental Checklist for Night Chest Pain

You need something you can run in your head at 3 a.m. while juggling three other crises. Keep it short.

When you hear “chronic chest pain” at night, do a quick mental pass:

Nighttime Chest Pain Resident Checklist

Step	Description
Step 1	Call about chest pain
Step 2	Ask what is different tonight
Step 3	Review vitals now
Step 4	Order and read EKG
Step 5	See patient, consider troponin and labs
Step 6	See patient, confirm unchanged chronic pattern
Step 7	Discuss with senior or cardiology if concerned
Step 8	Document reasoning and plan
Step 9	Any red flags?

If you cannot honestly say you ran through that sequence, you are cutting corners.

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Common Red Flags Residents Blow Off at Night

A few examples I see ignored over and over when someone says “chronic”:

• New O2 requirement for the same chest pain
• “Feels slightly different, I can’t describe it”
• New diaphoresis or nausea
• Lightheadedness or near-syncope with the pain
• Recent increase in diuretics, nitrates stopped, or beta-blocker missed
• Recent chemo, radiation, or long flight
• Chest pain in a post-op orthopedic or abdominal patient

Any one of these should override your sense of safety from the word “chronic.”

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FAQs

1. Do I really have to get an EKG for every chest pain call at night?

You do not need an EKG for every vague discomfort or non-cardiac complaint. But if the nurse, patient, or chart uses the words “chest pain” or “pressure,” the threshold should be extremely low. On the floor, a quick EKG is cheap, fast, and defensible. When in doubt, get it.

2. How many troponins should I order for “chronic” chest pain?

For very low-risk, fully unchanged, clearly non-cardiac pain, you may not need troponins at all. If there is any concern at all, at least one troponin plus an EKG is reasonable. If the story suggests possible ACS (especially onset within the last several hours), plan on serial troponins per your institution’s protocol and discuss with your senior.

3. What if my attending or senior tells me I am over-testing?

You are responsible for your own name in the chart. You can be judicious, but you are not required to be reckless to look “efficient.” Explain your concern succinctly: “They have chronic pain, but tonight is different because X, Y, Z, so I got an EKG and one troponin. Here is what I am seeing.” Most reasonable seniors will support that.

4. How do I document chronic chest pain safely at night?

Be explicit. Document:

• That the patient has a known history of similar pain.
• What you asked about changes and what the patient answered.
• The vital signs and EKG findings.
• Whether tonight’s episode is identical or how it differs.
• Your risk assessment and plan (including follow-up testing if any).

“Chronic chest pain, same as usual” with no qualifiers is how people end up in quality review meetings.

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Action for today: Open your last three night notes where you documented “chronic” or “atypical” chest pain. Read exactly what you wrote. Ask yourself: if this patient had ruled in for MI the next morning, would this documentation and evaluation hold up? If the answer is no, change how you handle the next 2 a.m. “chronic chest pain” call.