What are the causes of intermittent chest pain in a female patient?

Causes of Intermittent Chest Pain in a Female Patient

In women presenting with intermittent chest pain, cardiac causes must always be considered first due to the high risk of underdiagnosis, followed by systematic evaluation for pulmonary, gastrointestinal, musculoskeletal, and psychiatric etiologies. 1

Cardiac Causes (Life-Threatening Priority)

Acute Coronary Syndrome and Ischemic Heart Disease

• Women are at significant risk for underdiagnosis of cardiac causes and traditional risk assessment tools often underestimate their risk, misclassifying them as having nonischemic chest pain. 1
• Coronary artery disease remains the most common cardiac cause, presenting with retrosternal chest discomfort described as pressure, heaviness, tightness, or squeezing that may radiate to the jaw, neck, back, or arms. 1
• Women with acute myocardial infarction more frequently experience pain in the back, neck, and jaw compared to men. 1
• Women are more likely to present with accompanying symptoms including nausea, fatigue, shortness of breath, palpitations, jaw and neck pain, and back pain—often reporting ≥3 associated symptoms. 1
• Chest pain remains the predominant symptom in women with ACS, occurring with equal frequency to men, despite common misconceptions. 1

Coronary Microvascular Dysfunction

• Coronary microvascular disease causes myocardial ischemia even with completely normal-appearing epicardial coronary arteries on angiography—a critical diagnostic pitfall. 2
• Women have a higher proportion of acute coronary syndrome caused by coronary microvascular dysfunction compared to classical plaque rupture. 3
• Endothelial dysfunction is present in 80% of patients with angina and non-obstructive coronary artery disease. 2
• Traditional cardiovascular risk factors (hypertension, diabetes, dyslipidemia, smoking, age) cause structural and functional alterations in the coronary microvasculature. 2

Coronary Vasospasm

• Focal coronary spasm can cause complete or near-complete coronary occlusion, resulting in transmural ischemia and myocardial infarction without obstructive disease. 3
• Attacks occurring in clusters with early morning predominance (circadian variation) indicate higher myocardial infarction risk. 3
• Syncope during chest pain episodes suggests severe ischemia from acute occlusion due to focal spasm. 3

Other Cardiac Causes

• Aortic dissection presents with sudden onset of ripping chest pain ("worst pain of my life"), especially with radiation to the upper or lower back, particularly in hypertensive patients. 1
• Pericarditis causes sharp chest pain that increases with inspiration and lying supine. 1

Pulmonary Causes (Life-Threatening)

• Pulmonary embolism presents with chest pain, dyspnea, and tachycardia in >90% of patients, often with pain on inspiration. 1
• Pneumothorax causes sudden onset chest pain with dyspnea. 1
• Pneumonia can present with pleuritic chest pain. 1

Gastrointestinal Causes

• Gastroesophageal reflux disease and esophageal disorders account for 5-6% of chest pain presentations. 1
• Esophageal rupture is a life-threatening cause requiring immediate recognition. 1

Musculoskeletal Causes

• Musculoskeletal disorders are the most common cause in primary care settings, accounting for 43% of cases seen by general practitioners. 1
• Positional chest pain that can be localized to a very limited area is typically nonischemic (musculoskeletal). 1
• Pain that increases with palpation or movement suggests musculoskeletal origin. 1

Psychiatric Causes

• Anxiety, depression, and panic disorders account for 5-11% of chest pain presentations. 1
• Women may be overrepresented in chest pain due to psychiatric causes. 1
• Patients with chest pain without somatic diagnosis often suffer from psychiatric problems including anxiety, depression, or alcohol abuse. 1

Critical Diagnostic Approach for Women

High-Risk Features Requiring Immediate Evaluation

• Obtain a focused history emphasizing accompanying symptoms more common in women with ACS: nausea, vomiting, dyspnea, fatigue, palpitations, jaw/neck/back pain. 1
• Assess for traditional cardiovascular risk factors: hypertension, hyperlipidemia, diabetes, family history of premature CAD, sedentary lifestyle—all more prevalent in women with chest pain. 1
• Women with diabetes have higher prevalence of angina than men with lower functional capacity. 1

Pain Characteristics to Assess

• Fleeting chest pain of few seconds' duration is unlikely related to ischemic heart disease. 1
• Sharp chest pain that increases with inspiration and lying supine is unlikely related to ischemic heart disease. 1
• Anginal symptoms gradually build in intensity over several minutes. 1
• Pain radiating below the umbilicus or hip is unlikely related to myocardial ischemia. 1

Immediate Testing Requirements

• An ECG should be acquired and reviewed within 10 minutes of arrival for any acute chest pain presentation. 1
• The 12-lead ECG has sensitivity as low as 50% for identifying ischemia and more often misses myocardial infarction in women than men. 1
• High-sensitivity troponin testing with sex-specific thresholds has almost doubled the diagnosis of AMI in women. 4

Common Clinical Pitfalls

• Assuming normal epicardial coronary arteries on angiography exclude significant coronary disease—coronary microvascular disease can cause myocardial ischemia and adverse outcomes with completely normal-appearing vessels. 2
• Using the term "atypical chest pain" is not helpful and can be misinterpreted as benign; instead describe as cardiac, possibly cardiac, or noncardiac. 1
• Relying on nitroglycerin response as diagnostic—relief with nitroglycerin is not necessarily diagnostic of myocardial ischemia. 1
• Underestimating risk in women due to traditional risk score tools that often misclassify them as having nonischemic chest pain. 1