What are the differential diagnoses for a 34-year-old female with intermittent epigastric chest pain radiating to the back after exercise, with a history of anxiety and depression treated with Prozac (fluoxetine)?

Differential Diagnoses for Intermittent Epigastric Chest Pain Radiating to Back After Exercise in a 34-Year-Old Female

In this 34-year-old woman with exercise-induced epigastric pain radiating to the back, cardiac ischemia must be considered first despite her young age and female sex, as women are frequently underdiagnosed and their cardiac symptoms misclassified as noncardiac. 1

High-Priority Cardiac Differentials

Coronary Artery Disease/Angina

• Exercise as a precipitating factor is a classic trigger for anginal symptoms 1
• Women presenting with chest pain are at significant risk for underdiagnosis, and cardiac causes should always be considered first 1
• The epigastric location with back radiation fits the pattern seen in women with acute coronary syndrome, who commonly present with back pain, jaw pain, and epigastric symptoms more frequently than men 1
• The spasmodic quality does not exclude cardiac origin—women often describe atypical presentations 1
• Critical pitfall: Physician assessments often underestimate risk in women and misclassify their chest pain as nonischemic 1
• Even in young women, unusual cardiovascular abnormalities (congenital coronary anomalies, coronary artery dissection) can present with exertional chest pain 2

Coronary Vasospasm

• Can cause intermittent, exercise-related chest pain in young patients without obstructive coronary disease 3
• The spasmodic description is particularly suggestive 3

Gastrointestinal Differentials

Gastroesophageal Reflux Disease (GERD)

• Epigastric pain is a cardinal feature of GERD 1, 4
• Can radiate to the back and mimic cardiac pain 5
• Exercise can precipitate symptoms by increasing intra-abdominal pressure 1
• However, the consistent temporal relationship with exercise (not meals or position) makes this less likely as the primary diagnosis 4

Peptic Ulcer Disease

• Epigastric pain is characteristic 1
• Back radiation can occur with posterior penetrating ulcers 1
• Exercise relationship is atypical for PUD 1

Esophageal Spasm

• Can cause spasmodic chest pain that mimics cardiac pain 5
• May respond to nitroglycerin, creating diagnostic confusion 1

Musculoskeletal Differentials

Costochondritis/Chest Wall Pain

• The spasmodic quality could suggest musculoskeletal origin 4
• Key distinguishing feature: Pain should be reproducible with palpation and worsen with specific movements 4, 6
• Positional chest pain is usually nonischemic 1
• The consistent exercise trigger without positional variation makes this less likely 1

Anxiety-Related Chest Pain

Panic Disorder/Anxiety

• Given her history of anxiety and depression treated with Prozac, this warrants consideration 4, 5
• Anxiety disorders are common causes of chest pain in young adults 4
• However, the consistent exercise relationship and lack of other panic symptoms (palpitations, diaphoresis, sense of doom) makes this less likely as the sole explanation 4
• Psychological factors can worsen chest pain of any origin 5

Less Likely but Serious Differentials

Aortic Dissection

• Back radiation is characteristic 1
• Key distinguishing features: Sudden onset of "ripping" or "worst pain of life," not gradual buildup with exercise 1
• The intermittent nature and exercise relationship make this unlikely 1

Pulmonary Embolism

• Can cause exertional chest pain 1
• Would typically present with dyspnea, which is absent here 1

Recommended Diagnostic Approach

Immediate workup should prioritize cardiac evaluation:

1. 12-lead ECG within 10 minutes to assess for ischemia or injury patterns 4
2. Cardiac biomarkers (troponin) if any suspicion for acute coronary syndrome 4
3. Exercise stress testing is essential to identify ischemic heart disease and quantify myocardium at risk, given the exercise-related symptoms 6
4. Chest wall examination for reproducible tenderness to help exclude musculoskeletal causes 4, 6

If initial cardiac workup is negative:

• Consider upper endoscopy for GERD/PUD evaluation 1
• Trial of proton pump inhibitor therapy may be diagnostic and therapeutic for GERD 1, 5
• Reassess anxiety contribution only after excluding cardiac and gastrointestinal causes 4

Critical caveat: The combination of female sex, young age, and anxiety history creates a perfect storm for cardiac disease to be missed—maintain high suspicion for cardiac etiology until definitively excluded 1.