What is the appropriate diagnosis and treatment for a 47-year-old female experiencing increased shortness of breath and chest pain on exertion?

Evaluation and Management of a 47-Year-Old Female with Exertional Dyspnea and Chest Pain

This patient requires urgent cardiac evaluation with ECG and cardiac troponin measurement, as women presenting with exertional chest pain and dyspnea are at significant risk for underdiagnosis of acute coronary syndrome (ACS), and potential cardiac causes must always be considered. 1

Immediate Diagnostic Approach

History Taking - Critical Elements

• Obtain a focused history emphasizing accompanying symptoms more common in women with ACS, including nausea, fatigue, diaphoresis, lightheadedness, and upper abdominal discomfort, as these may be more prominent than chest pain itself in female patients 1
• Document chest pain characteristics: exertional/stress-related symptoms that are pressure-like, dull, squeezing, aching, gripping, or heavy in quality suggest high probability of ischemia 1
• Assess cardiovascular risk factors including family history, diabetes, hypertension, hyperlipidemia, and smoking history 1
• Determine if symptoms are progressive over weeks to months, as this pattern can indicate either worsening coronary disease or alternative diagnoses like interstitial lung disease 2

Physical Examination

• Perform focused cardiovascular examination to identify signs of heart failure (crackles, S3 gallop, mitral regurgitation murmur), aortic dissection (blood pressure differential, pulse deficits), or pulmonary embolism (tachycardia, tachypnea) 1
• Examine for signs of decompensation including diaphoresis, hypotension, or respiratory distress that would indicate higher acuity 1

Diagnostic Testing Algorithm

First-Line Testing (Within 10 Minutes)

• Obtain 12-lead ECG within 10 minutes of presentation to assess for ST-segment elevation MI, ST depression, transient ST-elevation, or new T-wave inversion 1
• Measure cardiac troponin as soon as possible after presentation if ACS is suspected 1
• Obtain chest radiograph to identify pulmonary causes, cardiomegaly, or pulmonary edema 1

Setting-Specific Considerations

• If evaluated in office setting without ECG capability, refer immediately to ED for ECG acquisition 1
• Transport urgently by EMS if clinical evidence of ACS is present; avoid delayed transfer for diagnostic testing 1

Advanced Imaging Based on Initial Results

• Transthoracic echocardiography is usually appropriate (rating 9/9) for evaluating cardiac structure, function, and wall motion abnormalities in dyspnea of suspected cardiac origin 1
• Chest CT with IV contrast (rating 7/9) may be appropriate if pulmonary embolism or aortic pathology is suspected 1
• Consider stress testing or coronary evaluation if initial workup suggests ischemic heart disease but acute MI is excluded 1

Differential Diagnosis Considerations

Cardiac Causes (Priority Given Age and Presentation)

• Acute coronary syndrome/unstable angina: most critical to exclude given exertional symptoms and female sex 1
• Stable angina with progression: exertional chest pain with dyspnea suggests coronary artery disease 1
• Cardiomyopathy or heart failure: can present with exertional dyspnea and chest discomfort 1
• Valvular heart disease: aortic stenosis or mitral regurgitation can cause exertional symptoms 1

Pulmonary Causes

• Pulmonary embolism: must be excluded in patients with dyspnea and chest pain 1
• Interstitial lung disease: progressive exertional dyspnea over months in a 47-year-old woman can indicate ILD 2
• Exercise-induced bronchoconstriction: consider if wheezing or reversible obstruction present, though less likely with chest pain 1

Other Considerations

• Perform spirometry and detailed pulmonary examination to determine if restrictive or obstructive lung disease contributes to symptoms 1
• Refer for cardiopulmonary exercise testing when breathlessness with chest pain might be caused by cardiac disease or other conditions requiring specialist evaluation 1
• Consider psychological evaluation only after organic causes are excluded, as anxiety can mimic cardiac symptoms but should not delay cardiac workup 1

Critical Pitfalls to Avoid

• Do not assume atypical symptoms exclude ACS in women: women are at higher risk for underdiagnosis, and accompanying symptoms like fatigue and dyspnea may predominate over chest pain 1
• Do not use nitroglycerin response as diagnostic criterion: relief with nitroglycerin occurs with esophageal spasm and other conditions, not just ischemia 1
• Do not delay cardiac evaluation for less urgent testing: if ACS is suspected, immediate ECG and troponin take precedence over other diagnostic considerations 1
• Do not attribute symptoms to anxiety or musculoskeletal causes without objective cardiac testing in a patient with cardiovascular risk factors 1