What are the next best steps for a 41-year-old female (F) with a history of smoking, currently using a nicotine patch, who experiences episodes of chest pain on the left side, with a past medical history of schizoaffective disorder and somatization, and normal vital signs?

Evaluation and Management of Chest Pain in a 41-Year-Old Female with Smoking History and Schizoaffective Disorder

For a 41-year-old female with a smoking history who is using a nicotine patch and experiencing left-sided chest pain, an ECG and cardiac troponin measurement should be obtained immediately to rule out acute coronary syndrome, even with a history of schizoaffective disorder and somatization.

Initial Assessment

History Elements to Focus On

• Chest pain characteristics:
  • Duration and frequency of the two episodes
  • Quality (pressure, sharp, burning, etc.)
  • Radiation to arm, neck, or jaw
  • Precipitating factors (exertion, stress)
  • Relieving factors (rest, position changes)
  • Associated symptoms (shortness of breath, nausea, diaphoresis)

Risk Factor Assessment

• Cardiac risk factors present:
  • Smoking history (significant risk factor)
  • Current nicotine patch use (may contribute to cardiovascular effects)
  • Age 41 (approaching increased risk age for women)
  • Female sex (women are at risk for underdiagnosis) 1

Physical Examination

• Focused cardiovascular examination to identify signs of ACS 1
• Vital signs are reported as normal, which is reassuring but does not rule out serious pathology

Diagnostic Testing

Immediate Testing

1. 12-lead ECG - Must be obtained within 10 minutes of presentation 2

   • Look for ST-segment elevation, depression, or T-wave inversions
   • If initial ECG is nondiagnostic but suspicion remains high, obtain serial ECGs 2

2. Cardiac troponin measurement - Should be performed as soon as possible 2

   • Serial measurements may be necessary (0,3,6 hours)

3. Basic laboratory tests:

   • Complete blood count
   • Basic metabolic panel
   • Coagulation studies if pulmonary embolism is suspected

Additional Testing Based on Initial Results

• If initial tests are negative but clinical suspicion remains:
  • Consider chest X-ray to evaluate for pulmonary or musculoskeletal causes
  • Consider additional cardiac testing (stress test or coronary CT angiography) if intermediate risk

Special Considerations

Smoking and Nicotine Patch

• Smoking is a significant risk factor for coronary artery disease 1
• Nicotine can cause coronary vasoconstriction and increase myocardial oxygen demand 1
• The combination of smoking history and current nicotine patch use increases cardiac risk

Schizoaffective Disorder Context

• Patients with schizoaffective disorder have high rates of smoking (67%) 3
• Psychiatric patients with chest pain are at risk for underdiagnosis of cardiac causes 1
• History of somatization should not lead to dismissal of potential cardiac causes 1
• Women who present with chest pain are at risk for underdiagnosis, and potential cardiac causes should always be considered 1

Differential Diagnosis

Cardiac Causes

• Acute coronary syndrome (unstable angina, NSTEMI, STEMI)
• Coronary artery spasm (can be precipitated by nicotine) 1
• Myocarditis or pericarditis

Non-Cardiac Causes

• Musculoskeletal pain (most common cause of chest pain in ED) 1
• Pulmonary (pneumothorax, pulmonary embolism)
• Gastrointestinal (GERD, esophageal spasm)
• Anxiety or panic disorder (common in psychiatric patients but a diagnosis of exclusion)

Management Algorithm

1. If ECG shows ST-segment elevation or other acute changes:

   • Immediate cardiology consultation
   • Consider acute coronary syndrome protocol

2. If ECG is non-diagnostic but troponin is elevated:

   • Admit for observation and serial troponins
   • Cardiology consultation

3. If both ECG and initial troponin are negative:

   • Continue with serial troponins
   • Consider additional cardiac testing if intermediate-high risk
   • Consider non-cardiac causes

4. If all cardiac testing is negative:

   • Consider non-cardiac causes
   • Do not dismiss symptoms as solely related to psychiatric diagnosis

Avoiding Common Pitfalls

1. Do not dismiss cardiac causes based on:

   • Normal vital signs (can be present in ACS)
   • History of schizoaffective disorder with somatization
   • Absence of "typical" symptoms (women often present atypically) 1

2. Do not use relief with nitroglycerin as a diagnostic criterion for myocardial ischemia, as other entities can show similar response 1

3. Do not describe chest pain as "atypical" - instead categorize as cardiac, possibly cardiac, or non-cardiac 1, 2

4. Do not delay ECG or troponin testing in patients with suspected ACS 2

5. Do not attribute symptoms to psychiatric diagnosis without appropriate cardiac workup 1

The patient's combination of smoking history, nicotine patch use, and left-sided chest pain warrants thorough cardiac evaluation regardless of psychiatric history. Cardiac causes must be ruled out first before attributing symptoms to non-cardiac or psychiatric causes.