What is the appropriate workup for a 37-year-old female presenting with central chest pain radiating to the jaw and back?

Workup for Central Chest Pain in a 37-Year-Old Female

A 37-year-old female presenting with central chest pain radiating to the jaw and around ribs to back requires immediate evaluation for acute coronary syndrome, despite her younger age, as women are at risk for underdiagnosis of cardiac causes. 1

Initial Assessment

History Elements to Focus On:

• Pain characteristics:
  • Onset and duration (gradual build over minutes suggests angina) 1
  • Quality (pressure, heaviness, tightness, squeezing suggests cardiac origin) 1
  • Radiation pattern (jaw and back radiation is common in women with ACS) 1
  • Associated symptoms (particularly those more common in women):
    • Nausea, vomiting, dyspnea, fatigue, palpitations 1
    • Diaphoresis (sweating) 1
  • Precipitating/relieving factors (exertion, rest, position changes) 1

Risk Factor Assessment:

• Cardiovascular risk factors (hypertension, hyperlipidemia, diabetes, smoking)
• Family history of premature CAD
• Previous cardiovascular disease

Immediate Diagnostic Steps

1. 12-lead ECG immediately - Should not be delayed 1

   • Look for ST-segment elevations, depressions, T-wave inversions, or new LBBB
   • Consider additional posterior leads (V7-V9) if standard ECG is non-diagnostic but suspicion remains high 2

2. Cardiac biomarkers - Troponin testing 1

   • Do not wait for results to initiate treatment if clinical suspicion is high 1
   • Serial measurements may be necessary (0,3,6 hours)

3. Chest radiography - To exclude other causes of chest pain 1

   • Rated highest (9/9) on appropriateness criteria for acute chest pain 1

Further Diagnostic Testing Based on Initial Results

If Initial Tests Suggest ACS or Are Inconclusive:

1. Transthoracic echocardiography 1

   • Evaluates wall motion abnormalities, cardiac function
   • Can help identify other causes of chest pain (aortic dissection, pericardial effusion)

2. Radionuclide perfusion imaging 1

   • Helpful in evaluating extent of ischemia
   • Particularly useful when initial screening tests suggest ischemic origin

3. Coronary CT angiography 1, 3

   • Consider in low to intermediate risk patients
   • Can rapidly rule out or confirm coronary artery disease
   • "Triple rule-out" protocol may be considered to simultaneously assess for:
     • Acute coronary syndrome
     • Pulmonary embolism
     • Acute aortic syndrome

4. Coronary angiography 1

   • May be necessary to define extent of stenosis
   • Typically performed later in workup unless high-risk features present

Important Considerations for Women

• Women with chest pain are at higher risk for underdiagnosis 1
• Women may present with both typical and atypical symptoms 1
• Women with ACS report chest pain with equal frequency to men, but often have more accompanying symptoms 1
• Traditional risk scores often underestimate risk in women 1

Differential Diagnosis to Consider

• Acute coronary syndrome (MI, unstable angina)
• Posterior myocardial infarction (may present with back pain) 2
• Aortic dissection (especially with sudden onset "ripping" pain) 1
• Pulmonary embolism
• Pericarditis
• Musculoskeletal pain (costochondritis)
• Gastroesophageal reflux disease
• Anxiety/panic disorder

Common Pitfalls to Avoid

1. Dismissing cardiac causes due to young age - Women of any age can experience ACS 1
2. Overlooking posterior MI - May present with interscapular pain; consider posterior leads 2
3. Misattributing symptoms to non-cardiac causes - Especially gastrointestinal symptoms 2
4. Waiting for "typical" presentation - Women may have different symptom patterns 1, 2
5. Relying solely on initial ECG - May be normal or non-diagnostic early in ACS 1

By following this systematic approach, you can ensure appropriate evaluation of central chest pain in this 37-year-old female, minimizing the risk of missed diagnosis and optimizing outcomes.