From the Guidelines
Red flags for acute chest pain in females include severe, crushing, or pressure-like pain that may radiate to the jaw, neck, back, or arms, as well as symptoms such as shortness of breath, nausea, vomiting, or sweating, which require immediate medical attention. According to the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1, women may experience atypical symptoms of heart attacks, including fatigue, indigestion, upper back pain, or dizziness. Key risk factors that increase concern include:
- Age over 55
- History of heart disease
- Diabetes
- High blood pressure
- High cholesterol
- Smoking
- Family history of heart disease
- Recent pregnancy complications
These factors, combined with symptoms like sudden onset of pain, especially during exertion, or pain that differs from previous episodes, necessitate prompt evaluation. The guideline emphasizes the importance of considering chest pain as part of a broader spectrum of symptoms, including pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw, as well as shortness of breath and fatigue 1. Women should not delay seeking medical care, as heart attacks often present differently in females, leading to potentially dangerous delays in treatment 1. If multiple red flags are present, it is crucial to call emergency services immediately rather than self-transporting to a hospital. The use of high-sensitivity troponins is recommended for establishing a biomarker diagnosis of acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury 1.
From the Research
Red Flags for Acute Chest Pain in Females
The following are red flags for acute chest pain in females:
- Age, with older females being at higher risk for coronary artery disease 2
- Type of chest pain, with certain characteristics increasing the likelihood of coronary artery disease as the cause of chest pain 3
- Electrocardiogram (ECG) changes, such as ST segment changes, new-onset left bundle branch block, presence of Q waves, and new T-wave inversions 3
- Positive troponin T or troponin I tests, which are strong predictors of cardiac events 4
- Persistent symptoms, such as throat pain, that may not be of cardiac origin but rather a sign of another concomitant critical disease 5
Diagnostic Considerations
When evaluating females with acute chest pain, consider the following diagnostic possibilities:
- Acute coronary syndrome (ACS) 6, 3
- Myocardial infarction (MI) 5, 4
- Aortic dissection 3
- Pulmonary embolism 3
- Acute pericarditis 3
- Pneumonia 3
- Heart failure 3
- Gastroesophageal reflux disease (GERD) 3
- Costochondritis 3
- Panic disorder or anxiety states 3
Evaluation and Triage
The evaluation and triage of females with acute chest pain should involve:
- A combination of age, sex, and type of chest pain to predict the likelihood of coronary artery disease as the cause of chest pain 3
- The use of clinical decision rules, such as the Marburg Heart Score and the INTERCHEST clinical decision rule, to estimate ACS risk 3
- Twelve-lead electrocardiography to look for ST segment changes and other abnormalities 3
- Troponin T or troponin I testing to detect cardiac-specific troponins 4
- Exercise stress testing, coronary computed tomography angiography, or cardiac magnetic resonance imaging for patients at low or intermediate risk of ACS 3