What is the initial workup for a 31-year-old female presenting with acute chest pain?

Initial Workup for a 31-Year-Old Female with Acute Chest Pain

For a 31-year-old female presenting with acute chest pain, an ECG should be obtained within 10 minutes of arrival, followed by cardiac troponin measurement to rule out acute coronary syndrome, even though cardiac causes are less common in this age group. 1

Step 1: Immediate Assessment

History

• Obtain a focused history of chest pain characteristics:
  • Nature: Retrosternal discomfort, pressure, tightness (suggests cardiac); sharp, stabbing pain (suggests non-cardiac)
  • Onset and duration: Gradual build over minutes (suggests cardiac); sudden ripping pain (suggests aortic dissection)
  • Location and radiation: Radiation to arms, neck, jaw (suggests cardiac)
  • Precipitating factors: Exercise, emotional stress (suggests cardiac); positional pain (suggests musculoskeletal)
  • Associated symptoms: Dyspnea, nausea, diaphoresis, lightheadedness (suggests cardiac) 1

Physical Examination

• Perform a focused cardiovascular examination to identify:
  • Signs of ACS: Diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3
  • Signs of other conditions: Friction rub (pericarditis), unilateral absence of breath sounds (pneumothorax), costochondral tenderness (costochondritis) 1

Step 2: Diagnostic Testing

Immediate Testing

1. ECG within 10 minutes of arrival - Look for:

   • ST-segment elevation (STEMI)
   • ST-depression or T-wave inversions (NSTEMI/unstable angina)
   • If initial ECG is nondiagnostic but suspicion remains high, perform serial ECGs 1

2. Cardiac troponin measurement

   • Should be measured as soon as possible after presentation
   • Delayed transfer for troponin testing should be avoided 1

Additional Testing Based on Initial Results

• If ECG shows ST-elevation: Activate STEMI protocol
• If ECG is nondiagnostic but suspicion remains high:
  • Consider supplemental ECG leads V7-V9 to rule out posterior MI
  • Serial troponin measurements
  • Consider additional imaging based on clinical suspicion 1

Step 3: Risk Stratification

High-Risk Features (Require Immediate Action)

• ST-segment elevation or depression
• Positive cardiac biomarkers
• Hemodynamic instability
• Severe, ripping pain (concern for aortic dissection)
• Pleuritic pain with respiratory distress (concern for PE or pneumothorax) 1

Special Considerations for Young Women

• Women are at risk for underdiagnosis of cardiac causes
• Pay special attention to accompanying symptoms that are more common in women with ACS:
  • Nausea, fatigue, shortness of breath, jaw/neck pain, back pain
  • Women may present with chest pain symptoms similar to men but often have additional symptoms 1

Step 4: Differential Diagnosis to Consider

1. Cardiac causes:

   • Acute coronary syndrome (less common but still possible in young women)
   • Myocarditis
   • Pericarditis (fever, pleuritic pain, friction rub)

2. Non-cardiac causes:

   • Pulmonary: Pneumonia, pulmonary embolism, pneumothorax
   • Gastrointestinal: Esophagitis, GERD, peptic ulcer disease
   • Musculoskeletal: Costochondritis (tenderness of costochondral joints)
   • Anxiety/panic disorder (common in young adults, but diagnosis of exclusion) 1

Common Pitfalls to Avoid

• Do not dismiss cardiac causes based on age alone - Young women can still have ACS 1, 2
• Do not use relief with nitroglycerin as a diagnostic criterion for myocardial ischemia 1, 3
• Do not delay ECG or troponin testing in patients with suspected ACS 1
• Do not rely solely on chest pain characteristics to rule out ACS - diagnostic testing is still needed 4
• Avoid describing chest pain as "atypical" - instead categorize as cardiac, possibly cardiac, or non-cardiac 3

Remember that while certain chest pain characteristics (stabbing, pleuritic, positional, reproducible by palpation) decrease the likelihood of ACS, the chest pain history alone is not powerful enough to rule out serious conditions without appropriate diagnostic testing 4.