What is the appropriate workup and differential diagnosis for a 60-year-old female with chest heaviness radiating to her back for 6 hours, without risk factors for cardiac disease, such as diabetes, hypertension, hyperlipidemia, or smoking?

Workup and Differential Diagnosis for a 60-Year-Old Female with Chest Heaviness

This patient with chest heaviness radiating to the back requires immediate evaluation for acute coronary syndrome despite lacking traditional risk factors, as women may present with atypical symptoms and radiation to the back raises concern for aortic pathology. 1

Initial Assessment and Stabilization

Immediate Actions

• Obtain 12-lead ECG within 10 minutes of presentation 2, 1
• Establish IV access and continuous cardiac monitoring 1
• Administer aspirin 162-325mg to be chewed (if not contraindicated) 1
• Obtain vital signs including oxygen saturation
• Provide supplemental oxygen if saturation <90% 1

Focused History

• Characterize chest discomfort: heaviness, pressure, tightness, squeezing 2, 1
• Radiation pattern: specifically to back (concerning feature) 2
• Duration: 6 hours (prolonged symptoms are concerning) 1
• Associated symptoms: absence of shortness of breath, edema 1
• Risk factor assessment: negative for traditional cardiac risk factors 1

Diagnostic Workup

Initial Testing (First Line)

1. 12-lead ECG - within 10 minutes of arrival 2, 1
2. Cardiac biomarkers - serial troponin at 0,3, and 6 hours 2, 1
3. Chest radiography - to evaluate for aortic pathology, pneumothorax, pneumonia 2
4. Basic laboratory tests - CBC, basic metabolic panel, coagulation studies

Secondary Testing (Based on Initial Results)

1. Transthoracic echocardiography - to assess wall motion, valvular function, aortic root 1
2. CT angiography of chest - if suspicion for aortic dissection or pulmonary embolism 2
3. Coronary CT angiography - to rapidly rule out or confirm coronary artery disease 1

Differential Diagnosis

High Priority Conditions (Life-threatening)

1. Acute Coronary Syndrome 2, 1

   • Despite lack of traditional risk factors, women may present with atypical symptoms
   • Chest heaviness for 6 hours is concerning for ongoing ischemia
   • Women are at higher risk for underdiagnosis 1

2. Acute Aortic Syndrome (dissection, intramural hematoma) 2, 1

   • Pain radiating to back is classic for aortic dissection
   • Sudden onset of pain that migrates from chest to back is highly suspicious

3. Pulmonary Embolism 2, 3

   • Can present with chest discomfort
   • Less likely without shortness of breath but cannot be excluded

Secondary Considerations

1. Esophageal Disorders 4

   • Gastroesophageal reflux disease
   • Esophageal spasm
   • Esophageal rupture (less likely without history of vomiting)

2. Musculoskeletal Pain 1

   • Less likely given radiation pattern and duration

3. Pericarditis 3

   • Usually sharp, positional pain
   • Often worse with lying flat or deep inspiration

Risk Stratification

HEART Score Components 5

• History: Moderately suspicious (2 points)
• ECG: Depends on findings (0-2 points)
• Age: 60 years (1 point)
• Risk factors: None mentioned (0 points)
• Troponin: Depends on results (0-2 points)

Management Based on Risk

• High-risk HEART score (7-10): Immediate cardiology consultation, consider invasive strategy 5
• Intermediate-risk HEART score (4-6): Observation, serial troponins, stress testing 5
• Low-risk HEART score (0-3): Consider early discharge if troponins negative 5

Special Considerations for Women

• Women with chest pain are at higher risk for underdiagnosis 1
• Women may present with both typical and atypical symptoms 1
• Absence of traditional risk factors does not exclude ACS in women 1
• Women may have microvascular coronary disease rather than obstructive CAD 1

Pitfalls to Avoid

1. Dismissing chest pain in women without traditional risk factors 1

   • Women are more likely to have ACS with normal coronary arteries

2. Relying on absence of ECG abnormalities during symptoms 6

   • Normal ECG does not exclude ACS, even when obtained during symptoms

3. Failing to consider aortic pathology with back pain radiation 2

   • Migration of pain from chest to back is classic for aortic dissection

4. Delaying transfer to emergency department 2

   • For patients with acute chest pain initially evaluated in office setting, delayed transfer for troponin testing should be avoided

5. Using nitroglycerin response as a diagnostic tool 7

   • Relief with nitroglycerin is not necessarily diagnostic of myocardial ischemia