What is the appropriate evaluation and management approach for women presenting with dyspnea (shortness of breath) to rule out cardiac causes?

Women with Dyspnea Require Systematic Cardiac Evaluation Due to High Risk of Underdiagnosis and Mortality

Women presenting with dyspnea are at substantial risk for missed cardiac diagnoses and should undergo systematic cardiac evaluation regardless of whether chest pain is present, as unexplained dyspnea alone carries more than twice the mortality risk of typical angina and increases sudden cardiac death risk 4-fold. 1

Why Women Are at Particular Risk

Atypical Presentation Patterns

• Women with acute coronary syndromes frequently present without chest discomfort—one-third of all MI patients lack chest pain, and these patients are disproportionately female, older, and diabetic 1
• Women often do not perceive themselves to be at cardiac risk, leading to delayed presentation and evaluation 1
• MI patients without chest discomfort experience significantly longer delays before hospital presentation (7.9 vs 5.3 hours) and are less likely to receive appropriate diagnosis and treatment 1

Mortality Impact of Missed Diagnosis

• Patients with silent MI (no chest discomfort) have 2.2 times higher in-hospital mortality (23.3% vs 9.3%) compared to those with typical chest pain 1
• Self-reported dyspnea alone independently predicts cardiac and total mortality, with 4-fold increased risk of sudden cardiac death even without prior CAD history 1
• Unexplained dyspnea carries more than twice the mortality risk compared to typical angina in patients undergoing cardiovascular evaluation 1

Mandatory High Index of Suspicion

Healthcare providers must maintain heightened suspicion for unstable angina/NSTEMI when evaluating women, particularly those with unexplained dyspnea, diabetes, older age, or history of heart failure or stroke. 1

High-Risk Patient Populations Requiring Cardiac Evaluation

• Women of any age presenting with dyspnea 1
• Patients with diabetes mellitus 1
• Older patients 1
• Those with unexplained dyspnea (even without angina) 1
• Patients with history of heart failure or stroke 1

Initial Diagnostic Approach

Essential First-Line Testing

• Chest radiography and ECG are standard initial tests but have limited sensitivity (59%) when chest X-ray is used alone, despite high specificity (96%) 1
• Transthoracic echocardiography (resting) is rated as "usually appropriate" (rating 9/9) and should be performed in all patients with dyspnea of suspected cardiac origin 1
• BNP or NT-proBNP measurement should be obtained in all patients with acute dyspnea—elevated levels warrant echocardiography 2, 3

Additional Cardiac Function Assessment

• Assessment of diastolic function and pulmonary artery pressures may be reasonable in women presenting with dyspnea 1
• For premenopausal women with functional disability, pharmacological stress echocardiography is recommended for identifying obstructive CAD and estimating prognosis 1

Advanced Imaging When Initial Testing Is Insufficient

Stress Testing Indications

• Stress echocardiography is recommended for symptomatic women at intermediate-high risk with: (a) resting ST-segment abnormalities, (b) functional disability, or (c) indeterminate/intermediate-risk stress ECG 1
• Stress imaging modalities help characterize cardiovascular etiologies including global or regional systolic dysfunction from myocardial ischemia 1

Anatomic Imaging

• Coronary CT angiography (CCTA) has emerged as a noninvasive alternative for determining presence, severity, and composition of coronary artery plaque 1
• Cardiac MRI with function and morphology assessment (with or without contrast) is rated as "usually appropriate" (rating 8-9/9) 1

Critical Pitfalls to Avoid

Common Diagnostic Errors

• Never assume dyspnea without chest pain is non-cardiac—this assumption leads to underdiagnosis and increased mortality in women 1
• Do not rely solely on telephone evaluation—patients with symptoms suggesting ACS must be evaluated in person by a physician 1
• Avoid dismissing symptoms as anxiety, musculoskeletal pain, or other benign conditions without systematic cardiac evaluation 1

Treatment Delays

• Women without chest discomfort are less likely to be diagnosed with MI on admission (22.2% vs 50.3%) and less likely to receive appropriate therapies including fibrinolysis, PCI, aspirin, beta blockers, or heparin 1
• Time-to-treatment is critical in acute heart failure patients—delays worsen outcomes 3

Non-Cardiac Mimics Requiring Consideration

While cardiac causes must be systematically excluded, the American College of Cardiology identifies important non-cardiac conditions that can mimic heart failure: 2

• Kidney failure presenting with dyspnea and edema 2
• Liver disease (particularly in patients with alcohol use) causing ascites and peripheral edema 2
• Chronic lung disease with or without cor pulmonale 2

The key principle is that cardiac causes must be actively ruled out through objective testing rather than assumed absent based on atypical presentation alone.