What is the recommended initial imaging for a 70-year-old female with chest pain that worsens with inspiration?

From the Guidelines

The recommended initial imaging for a 70-year-old female with chest pain that worsens with inspiration is a chest X-ray (CXR), as it can quickly identify conditions such as pneumonia, pneumothorax, pleural effusion, or rib fractures that might cause this symptom. Chest pain worsening with inspiration, known as pleuritic chest pain, suggests inflammation of the pleura or other conditions affecting the chest wall, lungs, or pleural space. According to the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain, chest tenderness on palpation or pain with inspiration markedly reduce the probability of acute coronary syndrome (ACS) 1.

Some key points to consider in the evaluation of this patient include:

• The patient's age and sex, which may increase the risk of certain conditions such as pulmonary embolism
• The presence of pleuritic chest pain, which suggests inflammation of the pleura or other conditions affecting the chest wall, lungs, or pleural space
• The need for prompt diagnosis and management of potentially serious conditions, such as pneumonia, pneumothorax, or pulmonary embolism

If the chest X-ray is negative but clinical suspicion for pulmonary embolism remains high (especially with risk factors like advanced age), a computed tomography pulmonary angiogram (CTPA) should be performed promptly 1. In some cases, an electrocardiogram (ECG) should also be obtained concurrently to rule out cardiac causes, as elderly patients may present atypically. The combination of pleuritic chest pain, advanced age, and female sex raises concern for potentially serious conditions that require prompt diagnosis, making appropriate imaging crucial for timely management.

From the Research

Initial Imaging Recommendations

For a 70-year-old female with chest pain that worsens with inspiration, the initial imaging recommendation can be guided by the following considerations:

• The patient's symptoms could suggest a pulmonary or cardiac etiology, given the association with inspiration.
• According to 2, Computed Tomography (CT) pulmonary angiography is a standard for evaluating acute pulmonary embolism and can also provide information on other potential causes of chest pain.
• However, the patient's presentation does not directly indicate pulmonary embolism without further symptoms such as dyspnea or hemoptysis.

Consideration of Patient Profile

• The patient's age and gender are relevant, as indicated by 3 and 4, which suggest that older females can present with a variety of chest pain causes, including cardiac and pulmonary issues.
• 4 notes that nonspecific chest pain is a common alternative diagnosis when pulmonary embolism is suspected, suggesting the need for a broad differential diagnosis.

Imaging Modalities

• CT angiography, as mentioned in 5, can be useful for evaluating coronary artery disease and other cardiovascular causes of chest pain, especially in low to intermediate risk patients.
• The "triple rule-out" protocol, also discussed in 5, can assess for acute coronary syndrome, pulmonary embolism, and acute aortic syndrome simultaneously but should be considered with caution due to increased radiation exposure.
• 6 emphasizes the role of imaging in evaluating chest pain in primary care settings, highlighting the importance of selecting the appropriate imaging modality based on the suspected etiology.

Decision Making

• Given the patient's symptoms and age, an initial evaluation with a chest radiograph may be useful to quickly assess for obvious pulmonary causes, as suggested by 2.
• Further imaging, such as CT pulmonary angiography or dedicated coronary CT angiography, may be warranted based on initial findings and clinical suspicion, considering the patient's risk factors and symptoms.
• Echocardiography, as mentioned in 2 for risk stratification in pulmonary embolism, could also be considered if cardiac causes are suspected.