What is the appropriate workup for a 20-year-old with intermittent chest pains and dyspnea (difficulty breathing)?

Workup for a 20-Year-Old with Intermittent Chest Pain and Dyspnea

The appropriate workup for a 20-year-old with intermittent chest pain and dyspnea should begin with chest radiography followed by transthoracic echocardiography, with subsequent testing guided by these initial findings. 1, 2

Initial Evaluation

First-Line Imaging

• Chest Radiography: Should be performed first to identify pulmonary causes, detect cardiomegaly, pulmonary edema, pleural effusions, or pneumomediastinum 1, 2
• 12-lead ECG: Essential to assess for cardiac arrhythmias, ischemic changes, or conduction abnormalities 2
• Transthoracic Echocardiography (TTE): Critical to evaluate cardiac structure and function, including:
  • Ventricular size and function
  • Valvular abnormalities
  • Pericardial disease
  • Pulmonary artery pressure estimation 1, 2

Laboratory Testing

• Complete blood count
• Basic metabolic panel
• Cardiac troponins
• BNP/NT-proBNP (especially if heart failure is suspected)
• Pulse oximetry to evaluate oxygenation status 2

Second-Line Testing Based on Initial Findings

If Cardiac Etiology is Suspected

• Stress Testing: Consider stress echocardiography, stress MRI, or stress SPECT to evaluate for ischemia, particularly if initial tests are inconclusive 1
• Cardiac MRI: Particularly useful for evaluation of:
  • Nonischemic cardiomyopathies
  • Myocarditis
  • Pericardial disease 1

If Pulmonary Etiology is Suspected

• Pulmonary Function Tests/Spirometry: To assess for airflow obstruction or restrictive patterns 2
• High-Resolution CT of the Chest: If interstitial lung disease or small airway disease is suspected 2
• Ventilation/Perfusion Scan: If pulmonary embolism is suspected 1

For Undifferentiated Cases

• Cardiopulmonary Exercise Testing (CPET): Gold standard for differentiating cardiac from pulmonary causes of exertional dyspnea 2
• Six-minute walk test: To objectively assess functional capacity 2

Special Considerations for Young Adults

Young adults with chest pain and dyspnea present unique diagnostic challenges:

1. Non-cardiac causes are more common but serious cardiac conditions must not be missed
2. Psychological factors may play a significant role - anxiety and panic disorders are common in this age group 1
3. Pneumomediastinum should be considered in young adults with acute chest pain and dyspnea, especially following trauma or exertion 3
4. Pulmonary hypertension can present with dyspnea and chest pain in young adults 1, 4

Risk Stratification

Young patients (<40 years) without known cardiac disease and with normal ECGs have a very low risk (<1%) of acute coronary syndromes 5. However, this should not lead to dismissing symptoms without appropriate evaluation.

Diagnostic Algorithm

1. Initial assessment: Chest radiography + ECG + TTE
2. If normal initial assessment:
   • Consider pulmonary function tests and/or CPET
   • Evaluate for non-cardiopulmonary causes (GERD, musculoskeletal)
   • Consider psychological causes (anxiety, panic disorder) 1
3. If abnormal initial assessment:
   • Direct further testing based on specific abnormalities
   • Consider referral to appropriate specialist (cardiology, pulmonology)

Common Pitfalls to Avoid

• Failing to recognize exercise-induced bronchoconstriction in patients with normal resting studies
• Not considering psychological causes when organic causes are ruled out
• Attributing symptoms to a single cause when multiple factors may be contributing
• Dismissing symptoms in young patients without thorough evaluation

Remember that up to one-third of cases of dyspnea have a multifactorial etiology 2, and the combination of chest pain with dyspnea requires careful evaluation even in young patients.