What could be causing my chest pain, shortness of breath, and fatigue, considering my history of chronic hives, family history of breast cancer, and recent echo findings?

Evaluation of Chest Pain, Shortness of Breath, and Fatigue in a 46-Year-Old Patient

Your symptoms of chest pain, shortness of breath, and profound fatigue with heart rate fluctuations (bradycardia to tachycardia) require urgent evaluation for cardiac causes, particularly acute coronary syndrome (ACS) and heart failure, despite your provider's initial assessment that symptoms are non-cardiac. 1

Immediate Cardiac Evaluation Required

You need comprehensive cardiac workup now, not reassurance alone. The combination of chest pain, dyspnea, and fatigue with documented heart rate abnormalities (HR 55 to 151 bpm) represents a classic presentation requiring exclusion of life-threatening cardiac conditions. 2

Priority Diagnoses to Exclude

• Acute Coronary Syndrome (ACS): Your chest pain worsening with elevated heart rate (>70-80 bpm), inability to complete routine tasks, and episodes of tachycardia followed by bradycardia are concerning for myocardial ischemia. Women frequently present with "atypical" symptoms including fatigue, shortness of breath, and chest discomfort rather than classic crushing chest pain. 1, 2

• Heart Failure: The triad of dyspnea, fatigue, and chest discomfort—particularly your inability to complete activities like climbing stairs or washing hair due to shortness of breath—strongly suggests heart failure. Your "hyperkinetic" echo at peak stress may indicate compensatory mechanisms. 1, 2, 3

• Arrhythmia: Your documented heart rate swings from 50s to 151 bpm with associated symptoms require evaluation for underlying rhythm disturbances beyond occasional PVCs. 1

Essential Diagnostic Testing

Immediate Laboratory Work

• Cardiac biomarkers: High-sensitivity troponin must be measured to exclude ACS, even if your provider believes symptoms are non-cardiac. 1, 2

• BNP or NT-proBNP: Values >500 pg/mL (BNP) or >1,000 pg/mL (NT-proBNP) strongly suggest heart failure as your cause of dyspnea and fatigue. 4, 3

• Complete metabolic panel and thyroid function: Your reported "subclinical" thyroid abnormality and borderline inflammatory markers need full characterization. 1

Cardiac Imaging

• Transthoracic echocardiography (TTE): Beyond your stress echo, a resting TTE is essential to evaluate for structural heart disease, valvular abnormalities, pericardial effusion, and ventricular function. The "hyperkinetic" finding at peak stress needs correlation with resting function. 1

• Continuous cardiac monitoring: Your episodic tachycardia and bradycardia require extended rhythm monitoring (Holter or event monitor) to capture arrhythmias. 1

Additional Imaging (Already Approved)

• CT angiography: Your approved CT should proceed urgently. If this is coronary CTA, it will definitively evaluate for obstructive coronary artery disease. 1

Non-Cardiac Considerations (Lower Priority)

Pulmonary Embolism

While your history of chronic hives and antihistamine use is noted, pulmonary embolism must be considered given chest pain, shortness of breath, and tachycardia. However, your clear prior chest CT and lack of unilateral leg symptoms make this less likely. 1, 2

Cervical Arthritis

Your anterior cervical fusion and cervical arthritis cannot cause shortness of breath or the pattern of symptoms you describe. Neck arthritis may cause referred pain but does not explain dyspnea, fatigue, or heart rate abnormalities. 1

Breast Cancer Screening

Your family history of breast cancer and overdue mammogram are important but unrelated to your acute cardiopulmonary symptoms. Breast cancer does not present with chest pain, shortness of breath, and heart rate fluctuations. Schedule your mammogram, but this is not causing your current symptoms. 1

Chronic Hives and Antihistamines

Your 3-year history of chronic hives treated with daily Allegra and previous Benadryl use is unrelated to your cardiac symptoms. Your appropriate discontinuation of Benadryl due to dementia risk was correct. 1

Critical Management Points

What Your Provider Should Do Now

1. Measure cardiac biomarkers immediately (high-sensitivity troponin, BNP/NT-proBNP) 1, 2, 3

2. Obtain 12-lead ECG to evaluate for ischemia, prior MI, or conduction abnormalities 1

3. Perform resting echocardiography to assess ventricular function, wall motion abnormalities, and valvular disease 1

4. Arrange continuous cardiac monitoring to capture your documented arrhythmias 1

5. Expedite the approved CT (coronary CTA if evaluating for CAD) 1

Common Pitfalls to Avoid

Do not dismiss your symptoms as "non-cardiac" based solely on a stress echo showing only occasional PVCs. Women are at significant risk for underdiagnosis of cardiac disease, and accompanying symptoms like fatigue and shortness of breath are more common in women with ACS than in men. 1, 2

Do not attribute all symptoms to anxiety or deconditioning when you have documented objective findings (heart rate 55 to 151 bpm, inability to complete activities of daily living). 2, 3

Your profound fatigue requiring you to delegate routine tasks and inability to attend church represents significant functional impairment that demands thorough cardiac evaluation, not reassurance alone. 2, 3

Medication Considerations

Your current gabapentin at lowest dose is appropriate for neuropathic pain but does not address cardiac symptoms. If heart failure is confirmed, you will likely need diuretics, ACE inhibitors/ARBs, and potentially beta-blockers (which would also address your tachycardia episodes). 4, 3

Urgent Next Steps

Advocate for same-day or next-day cardiology evaluation given your symptom severity and functional impairment. Your symptoms of chest pain with exertion, shortness of breath preventing completion of routine tasks, and documented heart rate abnormalities constitute an urgent cardiac evaluation, not a "wait and see" approach. 1, 2