What is the appropriate workup for a 21-year-old female presenting with intermittent chest pain?

Workup of Intermittent Chest Pain in a 21-Year-Old Female

In a 21-year-old female with intermittent chest pain and no cardiac history or risk factors, obtain a focused history emphasizing pain characteristics and perform a 12-lead ECG; if both are reassuring (noncardiac pain descriptors and normal ECG), cardiac causes are extremely unlikely (<1% risk), and you should pursue non-cardiac diagnoses including musculoskeletal pain, gastroesophageal reflux, and anxiety. 1

Initial Risk Stratification

Young adults presenting with chest pain have fundamentally different risk profiles than older patients. In patients aged 24-39 years without known cardiac disease and without any cardiac risk factors (hypertension, diabetes, hyperlipidemia, tobacco use, family history), the risk of acute coronary syndrome is 0.5% and the 30-day risk of adverse cardiovascular events (MI, death, revascularization) is 0%. 1 This evidence directly challenges the need for extensive cardiac workup in truly low-risk young patients.

However, women who present with chest pain are at risk for underdiagnosis, and potential cardiac causes should always be considered even in young patients. 2

Step 1: Obtain Focused History

Obtain a focused history that includes pain characteristics, duration, associated features, and cardiovascular risk factor assessment. 2

Pain Characteristics That Suggest Cardiac Origin:

• Retrosternal chest discomfort described as pressure, heaviness, tightness, squeezing, or constriction 2
• Pain that gradually builds in intensity over minutes 2
• Pain precipitated by physical exercise or emotional stress 2
• Pain radiating to arms (especially both arms), jaw, neck, or upper abdomen 2

Pain Characteristics That Suggest Non-Cardiac Origin:

• Sharp chest pain that increases with inspiration and lying supine 2
• Fleeting chest pain lasting only seconds 2
• Pain localized to a very limited area or reproducible with palpation 2
• Positional chest pain 2

Critical Point for Young Women:

In women presenting with chest pain, obtain a history that emphasizes accompanying symptoms more common in women with ACS, including palpitations, jaw and neck pain, back pain, nausea, fatigue, shortness of breath, and diaphoresis. 2 Women ≤55 years are equally likely to present with chest pain as men but are more likely to report ≥3 associated symptoms. 2

Assess Cardiac Risk Factors:

• Tobacco use (37% prevalence in young adults with chest pain) 1
• Hypertension (22% prevalence) 1
• Family history of premature CAD (19% prevalence) 1
• Diabetes mellitus (6% prevalence) 1
• Hyperlipidemia (6% prevalence) 1
• Prior cardiac history (3% prevalence) 1

Step 2: Perform 12-Lead ECG

Unless a noncardiac cause is evident, an ECG should be performed for patients seen in the office setting with stable chest pain; if an ECG is unavailable, the patient should be referred to the ED so one can be obtained. 2

In patients aged 24-39 without a cardiac history and with a normal ECG, the risk of ACS is 0.3% and the 30-day risk of adverse cardiovascular events is 0.3% (one death from metastatic cancer, no cardiac events). 1 This represents the lowest-risk cohort and can guide outpatient management.

Step 3: Physical Examination

Perform a focused cardiovascular examination to aid in diagnosis of ACS or other potentially serious causes (aortic dissection, pulmonary embolism, esophageal rupture) and to identify complications. 2

Key Examination Findings:

• Chest wall tenderness reproducible with palpation suggests musculoskeletal cause 2, 3
• Costochondritis presents with tenderness at costochondral junctions 2
• Epigastric tenderness suggests gastroesophageal or peptic ulcer disease 2
• Fever with localized chest pain suggests pneumonia 2

Step 4: Risk-Stratified Approach

Very Low Risk (No cardiac history, no risk factors, normal ECG):

• Pursue non-cardiac diagnoses without cardiac biomarkers or stress testing 1
• Consider musculoskeletal pain (most common in young adults) 3
• Consider gastroesophageal reflux disease 3, 4
• Consider anxiety or panic disorder (screen with two-item questionnaire) 4

Low-to-Intermediate Risk (Some risk factors OR abnormal ECG):

• Measure cardiac troponin as soon as possible if ACS is suspected 3
• If troponin elevated or ECG shows ischemic changes, transport immediately to emergency department 2, 5
• If initial workup negative but suspicion remains, consider outpatient exercise stress testing, coronary CT angiography, or cardiac MRI 5

Common Pitfalls to Avoid

Do not use the term "atypical chest pain" as it can be misinterpreted as benign; instead describe pain as cardiac, possibly cardiac, or noncardiac. 2 This is particularly important in women, where "atypical" presentations are actually common and lead to underdiagnosis. 2, 3

Do not use nitroglycerin response as a diagnostic criterion for myocardial ischemia, as esophageal spasm and GERD also respond to nitroglycerin. 2, 3

Do not assume symptoms are noncardiac based on young age alone—while overall ACS risk is 4.7% in patients aged 24-39, this drops to <1% only when both cardiac history and risk factors are absent. 1

Traditional risk score tools and physician assessments often underestimate risk in women and misclassify them as having nonischemic chest pain. 2

Most Likely Diagnoses in This Age Group

In young adults presenting to the ED with chest pain, the most common causes are: 2

• Musculoskeletal/chest wall pain (most common) 3
• Gastroesophageal reflux disease 3, 4
• Anxiety/panic disorder 4
• Costochondritis 2
• Pneumonia (if fever present) 2

Cardiac causes represent only 4.7% of cases overall in this age group, dropping to <1% in those without risk factors. 1