What causes hand numbness and occasional chest pain in a 72-year-old woman?

Hand Numbness and Occasional Chest Pain in a 72-Year-Old Woman

In a 72-year-old woman presenting with hand numbness and occasional chest pain, acute coronary syndrome (ACS) must be considered first and ruled out urgently, as older women are at high risk for underdiagnosis of cardiac causes and frequently present with atypical symptoms including extremity numbness rather than classic chest pain. 1

Immediate Cardiac Evaluation Required

Why Cardiac Causes Are Priority

• Women ≥75 years are at significant risk for ACS presenting with atypical symptoms including shortness of breath, syncope, acute delirium, or unexplained falls—and by extension, neurological symptoms like hand numbness should raise suspicion 1

• Older women are systematically underdiagnosed because physicians often misclassify their symptoms as noncardiac, and risk assessment tools frequently underestimate their cardiac risk 1, 2

• Hand numbness can represent referred pain or autonomic symptoms associated with cardiac ischemia, particularly in women who present with jaw pain, neck pain, back pain, and extremity discomfort more commonly than men 1, 2

• Age >75 years is itself a major risk factor for ACS, and alternative diagnoses, while more common than in younger patients, cannot be assumed without cardiac workup 1

Immediate Diagnostic Steps

• Obtain a 12-lead ECG within 10 minutes of presentation to assess for ST-elevation myocardial infarction (STEMI) or other ischemic changes 1

• Measure cardiac troponin (cTn) as soon as possible after presentation if ACS is suspected 1

• Obtain focused history emphasizing: accompanying symptoms more common in women with ACS (palpitations, jaw/neck pain, back pain, epigastric symptoms, diaphoresis, nausea) 1, 2

• Perform focused cardiovascular examination to identify complications and assess for other serious causes like aortic dissection or pulmonary embolism 1

Alternative Diagnoses After Cardiac Exclusion

Neurological Causes of Hand Numbness

Once cardiac causes are ruled out with negative troponin and ECG:

• Cervical radiculopathy or peripheral neuropathy are common causes of hand numbness in elderly patients, though these would not typically cause chest pain 3

• Thoracic outlet syndrome can cause both chest discomfort and hand numbness, particularly with positional changes 3

• Stroke or transient ischemic attack should be considered if hand numbness is unilateral, sudden onset, or associated with other neurological deficits 4

Musculoskeletal Causes

• Costochondritis or chest wall pain is the most common noncardiac cause of chest pain, but would need to be reproducible with palpation and positional 1, 5

• Cervical spine disease can cause both chest pain (referred) and hand numbness (radicular) 3

Gastrointestinal Causes

• Gastroesophageal reflux disease (GERD) can present with chest pain but would not explain hand numbness unless coincidental 1

• If chest pain is recurrent without cardiac or pulmonary cause, evaluation for gastrointestinal causes including upper endoscopy is reasonable 1

Rare but Serious Considerations

• Giant cell arteritis can present with chest pain, headache, jaw claudication, and neurological symptoms in elderly women, though hand numbness would be unusual 4

• Hyperventilation syndrome can cause both chest pain and bilateral hand numbness (paresthesias from respiratory alkalosis), though this is typically seen during acute episodes 6

Critical Pitfalls to Avoid

• Do not assume symptoms are noncardiac based on "atypical" presentation in an elderly woman—what is considered "atypical" is based on male symptom patterns 1, 2

• Do not delay transfer for diagnostic testing if initially evaluated in office setting; transport urgently to emergency department by EMS if ACS suspected 1

• Do not rely on nitroglycerin response as a diagnostic criterion for cardiac ischemia, as relief with nitroglycerin is not specific 1

• Do not attribute symptoms to anxiety or psychosomatic causes until comprehensive cardiac and neurological workup is negative 1

Recommended Diagnostic Algorithm

1. Immediate cardiac evaluation with ECG and troponin 1
2. If cardiac workup negative: neurological examination focusing on cervical spine, peripheral nerves, and cerebrovascular assessment 3, 4
3. If both cardiac and neurological workups negative: consider musculoskeletal evaluation with chest wall palpation and cervical spine imaging 1, 5
4. If all above negative and chest pain recurrent: gastrointestinal evaluation with trial of proton pump inhibitor or upper endoscopy 1