What is the differential diagnosis for an elderly female presenting with chest pain, considering her high risk for cardiovascular disease and potential comorbidities such as hypertension, hyperlipidemia, and previous cardiovascular events?

Differential Diagnosis for Chest Pain in an Elderly Female

In an elderly woman presenting with chest pain, acute coronary syndrome (ACS) must be the primary consideration and cannot be excluded based on "atypical" presentation—women ≥75 years are systematically underdiagnosed because physicians misclassify their symptoms as noncardiac, and age itself is a major independent risk factor for ACS. 1, 2

Life-Threatening Causes (Prioritize First)

Acute Coronary Syndrome

• Most critical diagnosis to exclude given that elderly women are at highest risk for underdiagnosis and delayed treatment 1
• Presents as retrosternal pressure, heaviness, tightness, or squeezing that may radiate to jaw, neck, arms, or back 1
• In women >75 years, ACS frequently presents with accompanying symptoms rather than isolated chest pain: shortness of breath, syncope, acute delirium, unexplained falls, nausea, fatigue, diaphoresis, palpitations, epigastric discomfort 1, 2
• Women with hypertension, hyperlipidemia, and previous cardiovascular events have significantly elevated risk (66.6% had hypertension, 68.9% had hyperlipidemia in PROMISE trial) 1
• Critical pitfall: Traditional risk scores underestimate cardiac risk in elderly women by up to 50% 1, 2

Aortic Dissection

• Sudden-onset tearing or ripping chest pain with radiation to upper or lower back 1, 3
• Consider in patients with hypertension, atherosclerosis, or known aortic pathology 4
• Examine for pulse deficits between extremities 4

Pulmonary Embolism

• Acute chest pain with dyspnea, may present similarly to ACS with elevated troponin 3, 5
• Can cause syncope and shock in massive PE 5
• Echocardiogram may show right ventricular dysfunction (McConnell's sign) 5

Tension Pneumothorax

• Acute onset chest pain with respiratory compromise 3
• Requires immediate recognition and decompression

Esophageal Rupture

• Life-threatening nonvascular emergency requiring urgent recognition 3

Non-Life-Threatening Causes (Consider After Excluding Above)

Gastroesophageal Reflux Disease (GERD)

• Epigastric pain that may mimic cardiac symptoms 2, 3
• Warning: Can respond to nitroglycerin, which is NOT diagnostic for cardiac ischemia 1, 2, 3

Musculoskeletal/Chest Wall Pain

• Reproducible with palpation, worsens with specific movements 3
• Positional chest pain is usually nonischemic 1
• Costochondritis shows localized tenderness at costochondral junctions 3

Pericarditis

• Sharp chest pain that increases with inspiration and lying supine 1
• Can mimic ACS presentation 4
• Inflammatory pericardial disease may present with acute chest pain 6

Peptic Ulcer Disease

• Epigastric pain that may radiate to back with posterior penetrating ulcers 3

Esophageal Spasm

• Can respond to nitroglycerin similar to cardiac ischemia 3

Immediate Diagnostic Algorithm

Within 10 Minutes of Presentation:

• Obtain 12-lead ECG to assess for ST-elevation MI, ST depression, or new T-wave inversion 2, 3, 7
• Measure cardiac troponin as soon as possible if ACS suspected 2, 3, 7

Focused History (Emphasize These Specific Elements):

• Accompanying symptoms more common in elderly women: jaw/neck pain, back pain, epigastric symptoms, palpitations, nausea, diaphoresis, fatigue, shortness of breath 1, 2
• Pain characteristics: pressure-like, dull, squeezing, aching, gripping, or heavy quality suggests ischemia 7
• Exertional or stress-related triggers 1, 7
• Document if unexplained falls, syncope, or acute delirium occurred 1, 2
• Cardiovascular risk factors: hypertension, hyperlipidemia, diabetes, family history, previous cardiovascular events 1, 7

Physical Examination:

• Focused cardiovascular exam to identify heart failure, aortic dissection, or pulmonary embolism 3, 7
• Check for pulse deficits suggesting aortic dissection 4
• Assess for chest wall tenderness (though presence does NOT exclude cardiac cause) 3

Additional Testing:

• Chest radiograph to identify pulmonary causes, cardiomegaly, or pulmonary edema 7
• High-sensitivity troponin if available (92% of women with ACS had chest pain in validation studies) 1

Critical Pitfalls to Avoid

• Never assume symptoms are noncardiac based on "atypical" presentation—what is considered "atypical" is based on male symptom patterns 2, 3
• Do not rely on nitroglycerin response as diagnostic criterion; esophageal spasm and GERD also respond 1, 2, 3
• Do not delay transfer to emergency department if initially evaluated in office setting and ACS suspected—transport urgently by EMS 2, 3
• Do not attribute symptoms to anxiety or psychosomatic causes until comprehensive cardiac workup is negative 2, 3
• Alternative diagnoses are more common than cardiac causes in patients >75 years, BUT this cannot be assumed without proper cardiac workup 1, 2

Special Considerations for This Population

• Elderly women with diabetes have higher prevalence of angina but paradoxically lower incidence of obstructive CAD on angiography 1
• Patients >75 years are more likely to have positive stress tests and coronary calcification 1
• A more extensive diagnostic workup is required in older patients due to higher comorbidity burden 1
• Women are less likely to receive timely and appropriate care despite higher symptom burden 1