From the Guidelines
For a 48-year-old female with chest pain, I recommend a comprehensive evaluation starting with a detailed history and physical examination, including an electrocardiogram (ECG), cardiac biomarkers (troponin levels), complete blood count, basic metabolic panel, and a chest X-ray, as the initial step in assessing potential cardiac origin of the chest pain, as suggested by the most recent guidelines 1. The workup should prioritize the identification of cardiac causes, given the potential for atypical presentations in women, as highlighted in a narrative review on heart disease in women 1. Key considerations in the initial assessment include:
- The patient's symptoms, which may be atypical, such as fatigue, shortness of breath, or pain in locations other than the chest
- The importance of early ECG and troponin measurement to identify potential myocardial infarction
- The need for a high index of suspicion for cardiac disease in women, even with atypical presentations If the initial assessment suggests cardiac origin, additional tests should include:
- A high-sensitivity troponin series (0,3, and 6 hours)
- Lipid profile
- Hemoglobin A1c Depending on risk factors and presentation, stress testing (exercise stress test or pharmacological stress test with imaging) may be appropriate, as outlined in guidelines for the management of acute coronary syndromes 1. For women, symptoms of cardiac disease can be atypical, so consider coronary CT angiography if there's intermediate risk, as suggested by the American College of Radiology Appropriateness Criteria for chest pain-possible acute coronary syndrome 1. Non-cardiac causes should also be investigated, including:
- Pulmonary embolism (D-dimer, CT pulmonary angiogram if D-dimer is positive)
- Gastroesophageal reflux (trial of proton pump inhibitor like omeprazole 20mg daily)
- Musculoskeletal pain (physical examination, trial of NSAIDs if appropriate)
- Anxiety-related chest pain (psychiatric evaluation if other causes are ruled out) The patient should be admitted for observation if there are concerning features such as abnormal ECG changes, positive troponin, or high-risk features like diabetes or family history of premature coronary artery disease, as emphasized in the 2024 American Heart Association and American Red Cross guidelines for first aid 1.
From the Research
Initial Assessment
The initial assessment of a 48-year-old female with chest pain involves a thorough clinical evaluation, including:
- A detailed medical history to identify risk factors for acute coronary syndrome (ACS) 2
- A physical examination to assess for signs of cardiac ischemia or other conditions that may cause chest pain 2
- An electrocardiogram (ECG) to evaluate for ST-segment elevation or depression, which can indicate ACS 3, 4
Diagnostic Testing
Diagnostic testing for ACS may include:
- Troponin measurements, with high-sensitivity troponin being the preferred test for evaluating non-ST-segment elevation myocardial infarction (NSTEMI) 3, 5
- Myocardial perfusion scintigraphy (SPECT) or other non-invasive tests to evaluate for coronary artery disease 4
- Serial troponin measurements to assess for changes in troponin levels over time 5
Risk Stratification
Risk stratification is critical in evaluating patients with chest pain, with the goal of identifying those at high risk for ACS who require prompt intervention:
- The HEART score and TIMI risk score are useful tools for risk stratification, incorporating factors such as medical history, ECG findings, and troponin levels 2
- Patients with a high-risk profile may require prompt invasive coronary angiography and revascularization, while those with a low-risk profile may be safely discharged with outpatient follow-up 3, 6
Management
Management of patients with chest pain suspected to be due to ACS involves: