In a 22‑year‑old woman with recurrent crushing chest pain radiating to the back and shoulders, a normal resting electrocardiogram and a normal exercise stress test, what is the most appropriate next step in evaluation and management?

Evaluation of Recurrent Chest Pain in a Young Woman with Normal Cardiac Testing

In a 22-year-old woman with recurrent crushing chest pain radiating to the back and shoulders, normal ECG, and normal stress test, the most appropriate next step is to screen for anxiety and panic disorders using validated tools, refer for cognitive-behavioral therapy, and consider a trial of proton-pump inhibitor therapy for possible gastroesophageal reflux disease—while avoiding repeat cardiac testing. 1, 2

Why Further Cardiac Testing Is Not Indicated

• The 2021 SAEM GRACE-1 guidelines explicitly state that in patients with recurrent, low-risk chest pain and a normal stress test within the previous 12 months, repeat routine stress testing is NOT recommended as a means to decrease rates of major adverse cardiovascular events at 30 days. 1

• Young age (22 years), normal resting ECG, and normal stress test place this patient in an extremely low pre-test probability category for obstructive coronary artery disease. 1

• The 2021 ACC/AHA guidelines recommend against routinely using further diagnostic testing (coronary CT angiography, stress testing, myocardial perfusion imaging) before discharge in low-risk patients in whom acute myocardial infarction has been ruled out. 1

Most Likely Differential Diagnoses

Musculoskeletal Pain (Most Common)

• Costochondritis accounts for the majority of chest pain cases in young adults when cardiac causes are excluded, characterized by tenderness of costochondral joints on palpation and pain reproducible with chest wall pressure. 2

• Musculoskeletal pain is typically sharp, localized, affected by breathing, turning, twisting, or bending. 2

• Point tenderness on examination strongly suggests musculoskeletal origin rather than cardiac pathology. 2

Anxiety and Panic Disorders (Very Common)

• Anxiety and panic disorders are common causes of chest pain in young adults, with a suspected psychogenic origin. 2, 3

• The 2021 SAEM GRACE-1 guidelines suggest the use of depression and anxiety screening tools in adult patients with recurrent, low-risk chest pain, as these might have an effect on health care use and return emergency department visits. 1

• The same guidelines suggest referral for anxiety or depression management, as this might have an effect on health care use and return emergency department visits. 1

Gastroesophageal Reflux Disease

• Gastroesophageal reflux disease can mimic cardiac pain, presenting as squeezing or burning sensations, and should be considered if pain occurs after meals or at night, or improves with antacids. 2, 4

• "Crushing" chest pain that radiates to the back can occasionally represent GERD, particularly in young patients without cardiac risk factors. 2, 4

Recommended Evaluation Approach

History Refinement

• Characterize pain by quality, location, radiation, onset, duration, precipitating factors, and relieving factors. 2, 3, 4

• Pain described as sharp, fleeting, related to inspiration, positional, or shifting locations suggests a lower likelihood of ischemia. 2, 3, 4

• Identify precipitating factors, such as exertion, stress, meals, breathing, or position changes, to help determine the cause of chest pain. 3

• Associated symptoms like dyspnea, diaphoresis, nausea, syncope, and palpitations should be noted. 3

Physical Examination

• Perform focused cardiovascular examination, assess for chest wall tenderness, and evaluate vital signs. 2, 3

• Assess for point tenderness which would suggest musculoskeletal origin rather than ischemia. 2, 4

Diagnostic Testing (If Not Already Done)

• A 12-lead ECG should be performed and interpreted within 10 minutes if any cardiac concern exists. 1, 2, 3

• Chest radiography is useful to identify pneumothorax, pneumonia, or mediastinal abnormalities if respiratory cause suspected. 2, 4

• Cardiac biomarkers (troponin) should only be used if initial evaluation suggests cardiac cause. 2

Management Strategy

Primary Interventions

• Treat musculoskeletal pain with NSAIDs if indicated. 2

• Consider referral to cognitive-behavioral therapist if anxiety is suspected with recurrent presentations. 2, 4

• For suspected gastrointestinal causes with recurrent symptoms, consider a trial of acid suppression therapy. 4

Follow-Up Planning

• Arrange follow-up in 1 to 2 weeks for low-risk patients in whom myocardial infarction has been ruled out. 1

• If symptoms persist after addressing musculoskeletal and psychological factors, consider expedited outpatient testing as warranted rather than admission for inpatient evaluation. 1

Critical Pitfalls to Avoid

• Do not order repeat cardiac testing (stress test, echocardiography, troponin) in patients who meet low-risk criteria, as it reinforces illness behavior and adds cost without improving outcomes. 4

• Assuming young age excludes acute coronary syndrome is incorrect, though the combination of young age, normal ECG, and normal stress test makes it extremely unlikely. 3

• Chest pain should not be described as "atypical" as this can be misinterpreted as benign; instead, characterize it as cardiac, possibly cardiac, or noncardiac. 3, 4

• Do not overlook psychological factors; only about 10% of clinicians record or refer for psychological factors even when patients self-report anxiety. 4

When to Reconsider Cardiac Evaluation

• Exertional chest pain with radiation to left arm, jaw, or neck requires immediate cardiac evaluation. 2

• Associated diaphoresis, dyspnea, nausea, or palpitations mandate urgent cardiac workup. 2

• Family history of premature coronary artery disease, hypertrophic cardiomyopathy, or sudden cardiac death requires immediate evaluation. 2

• History of Kawasaki disease with coronary involvement necessitates urgent assessment. 2