What are the next steps for investigating intermittent nocturnal chest pain in an 80-year-old female (YOF) with a history of controlled hypertension?

Evaluation of Intermittent Nocturnal Chest Pain in an 80-Year-Old Female with Controlled Hypertension

For an 80-year-old female with intermittent nocturnal chest pain and controlled hypertension, a 12-lead ECG should be performed immediately, followed by cardiac troponin measurement and echocardiography to evaluate for cardiac causes of chest pain. 1

Initial Assessment

Focused History

• Chest pain characteristics:
  • Nature: Determine if pain is retrosternal, squeezing, pressure-like (suggestive of cardiac origin) or sharp, stabbing (less likely cardiac) 1
  • Timing: Nocturnal pattern may suggest coronary vasospasm, heart failure, or gastroesophageal reflux disease
  • Duration: Episodes lasting minutes to hours (not seconds or days) are concerning for cardiac etiology
  • Radiation: Pain radiating to jaw, neck, arms, or between shoulder blades increases cardiac suspicion 1
  • Associated symptoms: Dyspnea, diaphoresis, nausea, lightheadedness (increase cardiac suspicion)

Risk Factor Assessment

• Age (80 years) and female sex: Advanced age significantly increases cardiovascular risk; women are at risk for underdiagnosis of cardiac causes 1
• Hypertension: Major risk factor for CAD, even when controlled 1
• Nocturnal pattern: May indicate heart failure exacerbation, vasospastic angina, or sleep apnea

Diagnostic Approach

Immediate Testing (Within 10 Minutes)

1. 12-lead ECG: Must be performed and reviewed within 10 minutes of presentation to evaluate for ST-segment elevation, depression, or T-wave inversions 1

Early Testing (Within 24 Hours)

1. Cardiac troponin measurement: Should be performed as soon as possible and repeated at 3-6 hour intervals to evaluate for myocardial injury 1, 2
2. Transthoracic echocardiography (TTE): To assess:
   • Left ventricular function
   • Regional wall motion abnormalities
   • Valvular disease (particularly aortic stenosis, common in elderly)
   • Signs of heart failure 1, 2

Additional Testing Based on Initial Results

1. Coronary evaluation: If initial tests suggest cardiac etiology:

   • Non-invasive: Coronary CT angiography (CCTA) or stress testing (pharmacological stress preferred in elderly)
   • Invasive: Coronary angiography if high suspicion of CAD or positive non-invasive testing 1

2. Extended evaluation if cardiac workup negative:

   • Chest X-ray to evaluate for pulmonary causes
   • Consider sleep study if nocturnal symptoms suggest sleep apnea
   • Gastroesophageal evaluation if reflux symptoms present

Special Considerations for Elderly Women

Women, particularly elderly women, often present with less typical symptoms of cardiac disease and are at risk for underdiagnosis 1, 2. Important considerations include:

• Higher prevalence of accompanying symptoms like dyspnea, fatigue, and nausea 1
• Higher likelihood of non-obstructive CAD or microvascular disease 3
• Increased risk of valvular heart disease, particularly aortic stenosis
• Potential for spontaneous coronary artery dissection (though more common in younger women) 4

Common Pitfalls to Avoid

1. Dismissing cardiac causes due to atypical presentation: Elderly women may not present with classic angina symptoms 1
2. Delaying ECG or troponin measurement: These should be obtained promptly, as delayed diagnosis increases mortality risk 1
3. Overlooking non-atherosclerotic causes: Consider aortic stenosis, vasospastic angina, and heart failure 1
4. Attributing symptoms to controlled hypertension alone: Even with controlled hypertension, patients remain at risk for CAD 5
5. Failing to consider nocturnal heart failure: Elderly patients may experience orthopnea manifesting as nocturnal chest pain

Follow-up Recommendations

• Close follow-up within 1-2 weeks if discharged without definitive diagnosis
• Optimization of antihypertensive therapy
• Consider aspirin and statin therapy if CAD is diagnosed
• Cardiac rehabilitation if CAD is confirmed

Remember that in elderly patients, especially women, cardiac causes of chest pain should always be considered even with atypical presentations, as this population is at high risk for adverse outcomes from missed cardiac diagnoses.