What are the possible causes of a left-sided dull ache in a 54-year-old woman?

Left-Sided Dull Ache in a 54-Year-Old Woman

A 54-year-old woman with left-sided dull ache requires immediate cardiac evaluation to exclude acute coronary syndrome (ACS), as women in this age group are at high risk for underdiagnosis of cardiac disease, particularly when presenting with atypical symptoms. 1, 2, 3

Immediate Life-Threatening Considerations

Cardiac Causes (Highest Priority)

Women presenting with chest pain—even when described as "dull" or "left-sided"—must have ACS considered as the primary diagnosis. 1, 2, 3 The 2021 AHA/ACC guidelines explicitly state that women are at significant risk for underdiagnosis and that cardiac causes should always be evaluated first. 1

• Obtain a 12-lead ECG within 10 minutes to identify ST-segment elevation, new ischemic changes, or T-wave inversions 1
• Measure high-sensitivity cardiac troponin immediately if ACS is suspected 1, 3
• Women aged 50-55 years present with chest pain as frequently as men but report ≥3 accompanying symptoms 62% of the time (vs. 55% in men) 1, 3

Critical accompanying symptoms to assess: 1, 2, 3

• Dyspnea, diaphoresis, nausea, or lightheadedness
• Jaw, neck, back, or epigastric pain
• Fatigue or palpitations
• Exertional provocation or occurrence at rest

Aortic dissection presents with sudden-onset "tearing" or "ripping" pain radiating to the back, particularly in hypertensive patients 1, 2

Pericarditis causes sharp, pleuritic pain that worsens supine and may have an associated friction rub 1, 2, 3

Pulmonary Causes

Pulmonary embolism (PE) occurs with tachycardia and dyspnea in >90% of cases, often with pleuritic pain 1, 2, 3

Pneumothorax presents with sudden pain, dyspnea, and unilateral absence of breath sounds 1, 2

Pneumonia causes localized, pleuritic pain with fever, dullness to percussion, and egophony 1, 2

Other Life-Threatening Causes

Esophageal rupture requires immediate recognition, presenting with chest pain and a painful, tympanic abdomen 1, 2, 4

Non-Life-Threatening Differential Diagnoses

Musculoskeletal Causes

Chest wall pain is positional, worsens with specific movements, and can be localized to a small area 1, 2

• Costochondritis demonstrates tenderness at costochondral junctions on palpation 1, 2
• Palpation tenderness markedly reduces ACS probability but does not exclude it 2, 3

Gastrointestinal Causes

GERD and esophageal spasm can mimic cardiac symptoms and may respond to nitroglycerin (though this is NOT diagnostic) 1, 4

Peptic ulcer disease presents with epigastric pain that may radiate 1, 4

Psychiatric Causes

Panic disorder/anxiety represents 5-11% of chest pain presentations, with women potentially over-represented 2

Diagnostic Algorithm

Step 1: Immediate Triage (Within 10 Minutes)

• 12-lead ECG to identify STEMI or ischemic changes 1
• Focused cardiovascular examination including blood pressure in both arms, cardiac auscultation for murmurs/rubs, and lung examination 1

Step 2: Risk Stratification

Assess cardiovascular risk factors: 1, 3

• Smoking history, diabetes, hypertension, hyperlipidemia
• Family history of premature CAD (onset <55 years in male relatives, <65 years in female relatives)
• Obesity, physical inactivity, peripheral artery disease

Step 3: Laboratory and Imaging

• High-sensitivity cardiac troponin as soon as possible if ACS suspected 1, 3
• Chest radiography if pulmonary cause suspected 1, 3
• Repeat troponin at 1-3 hours if initial is normal but suspicion remains 3

Step 4: Disposition Decision

If ECG shows STEMI or new ischemic changes: Immediate transfer by EMS to emergency department for emergent cardiac catheterization 3, 4

If ECG normal but troponin elevated: Urgent cardiology consultation and ED transfer 3

If both ECG and troponin normal but intermediate risk: Consider stress testing, coronary CT angiography, or cardiac MRI 3

Critical Pitfalls to Avoid

Never dismiss chest pain as non-cardiac based on "atypical" presentation (such as "dull" or "left-sided" descriptors) in a 54-year-old woman 1, 2, 3

Do not use nitroglycerin response as a diagnostic criterion for cardiac ischemia, as esophageal spasm and GERD can also respond 1, 4

Do not delay transfer to ED for troponin testing if initially evaluated in an office setting with suspected ACS 1

Avoid attributing symptoms to anxiety until comprehensive cardiac workup is negative 4

Women receive less timely and appropriate care despite greater symptom burden, so maintain high clinical suspicion 2, 3

Key Descriptors and Their Significance

According to the 2021 AHA/ACC guidelines, "dull" and "left-sided" descriptors have intermediate probability for ischemic origin 1. However, the guidelines emphasize that no single descriptor reliably excludes cardiac disease in women, particularly those in the perimenopausal age range. 1

High-probability descriptors for ischemia: pressure, squeezing, heaviness, tightness, exertional/stress-related 1

Lower-probability descriptors: sharp, stabbing, fleeting (seconds duration), pleuritic 1