What are the signs and symptoms of cardiac chest pain in women?

Signs of Cardiac Chest Pain in Women

Women with cardiac chest pain present with chest discomfort as frequently as men (87-92% of cases), but critically, they more often experience additional accompanying symptoms that must be actively sought to avoid underdiagnosis. 1

Primary Cardiac Chest Pain Characteristics in Women

Women experiencing cardiac ischemia typically describe:

• Retrosternal chest discomfort characterized as pressure, tightness, heaviness, squeezing, constriction, burning, or aching sensation 1, 2
• Gradual onset building in intensity over several minutes (not sudden or fleeting) 1
• Radiation to the neck, jaw, shoulders, back, or one or both arms 1, 2
• Provocation by physical exertion or emotional stress, or occurring at rest in acute coronary syndrome 1

Critical Accompanying Symptoms More Common in Women

The 2021 ACC/AHA guidelines emphasize that women are significantly more likely than men to present with ≥3 associated symptoms alongside chest pain, and these must be specifically elicited during history-taking. 1

Women more frequently report:

• Nausea and vomiting 1, 2
• Shortness of breath or dyspnea 1, 2
• Fatigue (often profound or unexplained) 1, 2
• Palpitations 1, 2
• Back pain (particularly between shoulder blades) 1, 2
• Jaw and neck pain 1, 2
• Epigastric pain or unexplained indigestion/belching 2
• Diaphoresis (sweating) 2
• Lightheadedness, confusion, presyncope, or syncope 1
• Dizziness 2

Critical Clinical Pitfalls to Avoid

Traditional risk assessment tools and physician clinical judgment systematically underestimate cardiac risk in women and frequently misclassify their chest pain as nonanginal. 1

Key considerations:

• Never dismiss cardiac causes in women presenting with chest pain - the ACC/AHA gives this a Class 1 recommendation 1
• Do not rely on nitroglycerin response as a diagnostic criterion, as esophageal spasm and other conditions respond similarly 1
• Women with diabetes warrant heightened suspicion, as they have higher angina prevalence than diabetic men and may present atypically due to autonomic dysfunction 1, 2
• Elderly women may present with generalized weakness, mental status changes, or syncope rather than classic symptoms 2

Special Population Considerations

Young women (≤55 years) present with chest pain as frequently as young men (87-89.5%), but 61.9% of young women report ≥3 associated symptoms compared to 54.8% of young men. 3

Women with cardiac events are typically:

• 8-10 years older than male counterparts at presentation 2
• More likely to have multiple cardiovascular risk factors including hypertension (66.6%), hyperlipidemia (68.9%), family history of premature CAD (34.6%), and sedentary lifestyle (53.5%) 1
• At higher risk for non-obstructive mechanisms including plaque erosion, coronary microvascular dysfunction, coronary vasospasm, spontaneous coronary artery dissection, and Takotsubo cardiomyopathy 2

Algorithmic Approach to Assessment

When evaluating women with chest pain:

1. Assume cardiac etiology until proven otherwise - women are at high risk for underdiagnosis 1
2. Specifically ask about all accompanying symptoms listed above, not just chest pain characteristics 1
3. Obtain immediate ECG for any woman with chest pain plus nausea, dyspnea, diaphoresis, or radiation patterns 2
4. Check cardiac biomarkers (troponin) in women with concerning symptoms or risk factors 2
5. Perform comprehensive cardiovascular risk factor assessment including diabetes, hypertension, hyperlipidemia, family history, and smoking 1, 2