What is the appropriate workup for a patient with chest pain on exertion, considering potential cardiac causes and risk factors such as age, sex, history of cardiovascular disease, hypertension, diabetes, or hyperlipidemia?

Workup for Chest Pain on Exertion

For a patient presenting with exertional chest pain, immediately obtain a 12-lead ECG within 10 minutes and measure cardiac troponin to rule out acute coronary syndrome, followed by risk stratification using clinical characteristics and stress testing or coronary CT angiography for intermediate-risk patients. 1

Initial Assessment

Immediate Actions

• Obtain a 12-lead ECG within 10 minutes of presentation to assess for ST-elevation MI, ST-segment depression, or new T-wave inversions 1
• Draw cardiac troponin (preferably high-sensitivity troponin) immediately upon presentation, with repeat measurement at 10-12 hours after symptom onset if initial value is normal 1
• Perform serial ECGs if the initial ECG is nondiagnostic but clinical suspicion remains high, especially if symptoms persist or worsen 1

Focused History

Characterize the chest pain using these specific features 1:

Quality and Location:

• Retrosternal discomfort described as pressure, heaviness, tightness, squeezing, or constriction suggests angina 1
• Sharp pain that increases with inspiration or lying supine is unlikely ischemic (suggests pericarditis) 1
• Pain localized to a very small area or radiating below the umbilicus is unlikely myocardial ischemia 1

Temporal Pattern:

• Anginal symptoms build gradually over several minutes 1
• Fleeting pain lasting only seconds is unlikely cardiac 1
• Sudden-onset "ripping" pain radiating to the back suggests aortic dissection, not angina 1, 2

Precipitating Factors:

• Physical exertion or emotional stress are classic triggers for angina 1
• Symptoms occurring at rest or with minimal exertion suggest acute coronary syndrome 1
• Positional chest pain is usually nonischemic (musculoskeletal) 1

Associated Symptoms:

• Dyspnea, diaphoresis, nausea, lightheadedness, or syncope commonly accompany myocardial ischemia 1
• Women, elderly patients, and diabetics may present with atypical symptoms including jaw/neck pain, back pain, epigastric discomfort, or isolated dyspnea 1, 3, 4

Physical Examination

Perform a targeted cardiovascular examination 1:

• Vital signs: Tachycardia, hypotension, or diaphoresis suggest acute coronary syndrome 1
• Cardiac auscultation: Listen for S3 (heart failure), new mitral regurgitation murmur (papillary muscle ischemia), or aortic stenosis 1
• Pulse differential: Check for extremity pulse differences suggesting aortic dissection 1, 2
• Chest wall palpation: Reproducible pain with palpation suggests musculoskeletal cause, making ischemia less likely 1, 2

Risk Stratification

High-Risk Features Requiring Immediate Intervention

Patients with any of the following require urgent coronary care unit admission 1:

• ST-segment elevation or new left bundle branch block on ECG 1
• Elevated cardiac troponin 1
• Hemodynamic instability (hypotension, pulmonary edema) 1
• Ongoing severe chest pain despite initial treatment 1

Intermediate-Risk Patients (Normal ECG and Troponin)

For patients with normal initial ECG and troponin but concerning clinical features, assess these independent predictors of adverse events 5:

• Chest pain characteristics score ≥11 points (based on typical anginal features) 5
• Diabetes mellitus 5
• Previous coronary artery bypass surgery 5
• ST-segment depression on ECG (even if not meeting STEMI criteria) 5

Risk stratification based on number of predictors present 5:

• 0-1 predictors: 2.7% event rate at 6 months
• 2 predictors: 10.2% event rate
• 3-4 predictors: 29.2% event rate

Low-Risk Patients

Patients may be considered low-risk if they have 6, 7:

• Age <40 years with no cardiac history, no cardiac risk factors, and normal ECG (event rate <1%) 6
• HEAR score <2 or HE-MACS score indicating very low risk 7

However, do not assume low risk based solely on age or "atypical" presentation, especially in women, elderly patients, or diabetics 3, 4

Diagnostic Testing Strategy

For Intermediate-Risk Patients with Normal Initial Workup

Early exercise stress testing (within 24 hours) is highly effective for risk stratification in patients with normal troponin and physical capacity 1, 5:

• Negative exercise test: 0% event rate at 6 months 5
• Positive or non-diagnostic test: Proceed to coronary angiography or advanced imaging 5

Alternative Noninvasive Testing

For patients unable to exercise or with baseline ECG abnormalities 1:

• Stress echocardiography or stress cardiac MRI with pharmacologic stress 1
• Coronary CT angiography for anatomic assessment in intermediate pretest probability patients 1
• Cardiac PET imaging can identify coronary microvascular dysfunction in patients with persistent symptoms and normal coronary arteries 8

Special Population Considerations

Women

• Maintain a lower threshold for cardiac evaluation as women are systematically underdiagnosed 3, 4
• Women more commonly present with accompanying symptoms (jaw/neck pain, back pain, nausea, diaphoresis, palpitations) rather than isolated chest pain 1, 3, 4
• Traditional risk scores underestimate cardiac risk in women by up to 50% 4
• Do not dismiss symptoms as "atypical"—this terminology is based on male presentation patterns 3, 4

Elderly Patients (≥75 years)

• Age itself is a major independent risk factor for acute coronary syndrome 4
• May present with isolated dyspnea, syncope, acute delirium, or unexplained falls rather than chest pain 4
• Require more extensive diagnostic workup due to higher comorbidity burden 4

Diabetic Patients

• May have atypical presentations including isolated dyspnea or epigastric discomfort 1
• Diabetes is an independent predictor of adverse cardiac events 5
• Women with diabetes have higher prevalence of angina but paradoxically lower rates of obstructive CAD on angiography 1, 4

Critical Pitfalls to Avoid

• Never use nitroglycerin response as a diagnostic criterion for myocardial ischemia—esophageal spasm and GERD also respond to nitroglycerin 1, 2, 4
• Do not discharge patients with normal initial troponin without further risk stratification if they have concerning clinical features—4.8% of such patients have adverse events at 6 months 5
• Do not assume cardiac disease is excluded based on young age alone—while overall risk is lower, 4.7% of patients aged 24-39 with chest pain have acute coronary syndrome 6
• Do not attribute symptoms to anxiety or psychosomatic causes until comprehensive cardiac workup is negative, especially in women 3, 4
• Do not rely solely on traditional risk scores as they systematically underestimate risk in women and contemporary populations 3, 4

Observation Strategy

For patients requiring extended evaluation, utilize a chest pain observation unit for 10-12 hours after symptom onset 1:

• Serial troponin measurements 1
• Continuous ST-segment monitoring (12-lead preferred over 3-lead) 1
• Early stress testing before discharge if troponins remain negative 1, 5

This approach reduces inappropriate discharge of patients with undiagnosed acute coronary syndrome while avoiding unnecessary admissions 1, 6