What are the next steps for a 62-year-old female with hypertension (HTN) experiencing chest pressure and pain that wakes her from sleep, lasting one hour, with no changes in electrocardiogram (EKG)?

Evaluation and Management of Chest Pain in a 62-Year-Old Female with Hypertension

For a 62-year-old female with hypertension experiencing chest pressure and pain that woke her from sleep, lasting one hour with no EKG changes, urgent cardiac evaluation is necessary, including echocardiography to assess for structural heart disease and stress testing to evaluate for myocardial ischemia.

Initial Assessment and Risk Stratification

• Chest pain that wakes a patient from sleep and lasts for one hour represents a concerning symptom that requires prompt evaluation, even without EKG changes 1
• The patient's age (62), female sex, and history of hypertension are significant risk factors for coronary artery disease 1
• This presentation could represent unstable angina, which requires urgent evaluation despite normal EKG findings 1
• Severe prolonged chest pain calls for immediate action regardless of cause, as it could indicate several potentially life-threatening conditions including unstable angina, aortic aneurysm, pulmonary embolism, or other serious cardiac conditions 1

Diagnostic Workup

Immediate Testing

• Obtain cardiac biomarkers (high-sensitivity troponin) to rule out myocardial infarction, as normal EKG does not exclude cardiac damage 1
• Transthoracic echocardiography is strongly recommended to assess for:
  • Left ventricular hypertrophy (common in hypertensive patients) 1
  • Regional wall motion abnormalities that might indicate ischemia 1
  • Left ventricular systolic and diastolic function 1
  • Left atrial size (an enlarged left atrium ≥34 mL/m² is an independent predictor of adverse outcomes) 1

Additional Testing

• Stress testing is warranted due to the concerning nature of symptoms despite normal EKG 1
  • When exercise ECG is uninterpretable or ambiguous, an imaging test of inducible ischemia such as stress echocardiography, perfusion scintigraphy, or stress cardiac MRI is recommended 1
  • Stress-induced wall motion abnormalities are highly specific for epicardial coronary artery stenosis 1
• Consider 24-hour Holter monitoring to detect arrhythmias that might have occurred during the episode 1
• Laboratory testing should include electrolytes, glucose, and thyroid studies to assess for secondary causes of symptoms 1

Management Approach

Immediate Management

• If symptoms recur, the patient should be instructed to take fast-acting aspirin (250-500 mg) and seek immediate medical attention 1
• Short-acting nitrates may be considered for symptom relief if there is no bradycardia or hypotension 1

Hypertension Management

• Optimize blood pressure control as hypertension doubles stroke risk and contributes to coronary disease 1
• Consider echocardiography-guided therapy if left ventricular hypertrophy is detected 1
• First-line antihypertensive therapy should include:
  • Thiazide or thiazide-like diuretics 2
  • ACE inhibitors or angiotensin receptor blockers 2
  • Calcium channel blockers 2
• Beta-blockers should be considered if coronary artery disease is confirmed 1

Follow-up Recommendations

• If initial cardiac evaluation is negative but symptoms are highly suspicious for cardiac origin, consider:
  • Coronary CT angiography to evaluate for coronary artery disease 1
  • Cardiac MRI if echocardiography is technically difficult or inconclusive 1
• Regular follow-up to monitor blood pressure control and symptom recurrence 1
• Repeat echocardiography if the patient becomes symptomatic or if there are changes in clinical status 1

Important Considerations and Pitfalls

• Do not dismiss chest pain in women, as they often present with atypical symptoms and may have normal EKGs despite significant coronary disease 1
• Normal EKG during pain-free periods does not exclude significant coronary artery disease 1
• Hypertension can cause microvascular coronary disease that may not be detected on standard coronary angiography but can cause significant symptoms 1
• Avoid dismissing symptoms as non-cardiac without thorough evaluation, especially in patients with hypertension who are at increased risk for cardiovascular events 1