What diagnostic tests should be ordered for an 85-year-old female with chest pain?

Diagnostic Tests for an 85-Year-Old Female with Chest Pain

For an 85-year-old female with chest pain following a COVID-19 injection, a comprehensive cardiac evaluation is recommended, starting with an electrocardiogram (ECG) and high-sensitivity troponin measurements to rule out acute coronary syndrome, despite her recent negative stress test and echocardiogram. 1

Initial Evaluation

• Obtain a 12-lead ECG within 10 minutes of presentation to evaluate for STEMI or other acute cardiac conditions 1
• Draw blood for high-sensitivity cardiac troponin (hs-cTn) measurements, which is the preferred biomarker due to its greater diagnostic accuracy and rapid detection of myocardial injury 2
• For conventional troponin assays, measurements should be taken 3-6 hours apart; for high-sensitivity troponin, 1-3 hours between measurements 2
• Obtain a chest radiograph to evaluate for cardiac, pulmonary, and thoracic causes of chest pain, including pneumonia, pneumothorax, or rib fractures 2
• Perform a focused cardiovascular examination to identify signs of cardiac compromise and evidence of non-cardiac causes 1

Risk Stratification

• Despite recent negative stress test and echocardiogram, consider the patient at intermediate risk due to age, history of mild CAD, and paroxysmal atrial fibrillation 1, 3
• Older patients (≥75 years) often present with atypical symptoms of ACS, including shortness of breath, syncope, or acute delirium 1, 3
• The likelihood of cardiac causes of chest pain increases substantially with age, with patients over 75 years accounting for approximately 33% of all acute coronary syndrome cases 3

Cardiac Testing

• Coronary computed tomography angiography (CCTA) is useful for exclusion of atherosclerotic plaque and obstructive CAD in intermediate-risk patients with acute chest pain and no known CAD eligible for diagnostic testing after a negative or inconclusive evaluation for ACS 1
• If CCTA is contraindicated or unavailable, stress imaging with echocardiography, PET/SPECT myocardial perfusion imaging, or cardiovascular magnetic resonance (CMR) is useful for diagnosing myocardial ischemia 1
• Consider transthoracic echocardiography (TTE) to evaluate for wall motion abnormalities and assess for pericardial effusion 2

Non-Cardiac Considerations

• D-dimer testing should be performed to evaluate for pulmonary embolism, especially given the temporal relationship to COVID-19 vaccination 4, 5
• If D-dimer is elevated, proceed with CT pulmonary angiogram to rule out pulmonary embolism 4, 6
• Consider evaluating for pericarditis with ECG (looking for diffuse ST elevations) and echocardiography, as this could be related to the COVID-19 vaccine, although rare 7, 6

Contraindications to Testing

• For exercise ECG: abnormal ST changes on resting ECG, inability to achieve ≥5 METs, uncontrolled heart failure, significant cardiac arrhythmias 1
• For stress nuclear imaging: significant arrhythmias, contraindications to vasodilator administration, known or suspected bronchospastic disease 1
• For CCTA: allergy to iodinated contrast, renal impairment, inability to cooperate with scan acquisition, contraindication to beta blockade with elevated heart rate 1

Algorithm for Testing Selection

1. Start with ECG and high-sensitivity troponin measurements 1, 2
2. Obtain chest radiograph 2
3. If initial evaluation is negative for ACS:
   • CCTA is preferred if no contraindications exist 1
   • If CCTA is contraindicated, proceed with stress imaging (echocardiography, PET/SPECT MPI, or CMR) 1
4. If D-dimer is elevated, proceed with CT pulmonary angiogram 4, 6
5. If suspicion for pericarditis exists, obtain echocardiography 7, 6

Special Considerations for This Patient

• Given her age and history of paroxysmal atrial fibrillation, consider ambulatory ECG monitoring to detect potential arrhythmias that could be causing chest discomfort 3, 8
• Despite recent negative stress test, maintain a lower threshold for suspecting ACS in this elderly female patient, as presentations can be atypical 1, 3
• The temporal relationship to COVID-19 vaccination warrants consideration of rare vaccine-related adverse events such as myocarditis or pericarditis 7, 6