For a 43‑year‑old woman with hypertension (on losartan) and prior total hysterectomy, presenting with three‑day intermittent dull central chest pain radiating to the back and neck, lasting about five minutes, 7/10 severity, partially relieved by cold water, and with normal vital signs and physical exam, what is the most likely diagnosis and what immediate diagnostic and management steps are indicated?

Most Likely Diagnosis and Immediate Management

This 43-year-old woman with hypertension presenting with intermittent central chest pain radiating to the back and neck, partially relieved by cold water, requires immediate exclusion of acute coronary syndrome (ACS) and esophageal pathology through 12-lead ECG within 10 minutes and high-sensitivity cardiac troponin measurement, despite normal vital signs and physical examination. 1

Life-Threatening Conditions to Exclude First

Acute Coronary Syndrome

• Women are at high risk for underdiagnosis of ACS because they frequently present with atypical symptoms including throat discomfort, nausea, and fatigue rather than classic chest pain. 1, 2
• Central chest pain radiating to the neck is a recognized pattern of myocardial ischemia in women, even when described as "dull" rather than pressure-like. 1, 3
• A completely normal physical examination does NOT exclude uncomplicated myocardial infarction; up to 30-40% of acute MIs present with normal or nondiagnostic initial findings. 1, 3
• Sharp or atypical pain quality does not rule out ACS; approximately 13% of patients with pleuritic-type pain still have acute myocardial ischemia. 1, 3

Aortic Dissection

• Sudden "ripping" or "tearing" chest pain radiating to the back is the classic presentation, but this patient's gradual onset over 3 days makes dissection less likely. 1, 3
• Hypertension (on losartan) is a major risk factor for aortic dissection and must be considered. 1
• Measure blood pressure in both arms to detect systolic BP difference >20 mmHg, which occurs in aortic dissection. 1, 3

Pulmonary Embolism

• Sudden dyspnea with pleuritic chest pain is typical, but this patient denies dyspnea. 1, 3
• Tachycardia occurs in >90% of PE patients; normal vital signs make PE less likely but do not exclude it. 1, 3

Most Probable Diagnosis: Esophageal Pathology

Gastroesophageal Reflux Disease (GERD) / Esophageal Spasm

• Relief with cold water strongly suggests an esophageal cause; GERD and esophageal spasm characteristically improve with cold liquids or antacids. 1, 3
• Central chest pain lasting 5 minutes with radiation to the neck can mimic cardiac ischemia but is consistent with esophageal dysmotility. 1, 3
• Gastrointestinal causes account for 10-20% of chest pain in outpatient settings, with GERD being the most common esophageal etiology. 1, 3
• Esophageal spasm may respond to nitroglycerin, which is why nitroglycerin response should NOT be used to differentiate cardiac from esophageal pain. 1, 3

Immediate Diagnostic Steps (First 10 Minutes)

Mandatory Initial Testing

• Obtain 12-lead ECG within 10 minutes to identify ST-elevation, ST-depression, T-wave inversions, or other acute ischemic changes. 1, 3, 4
• Measure high-sensitivity cardiac troponin immediately when ACS is suspected; it is the most sensitive and specific biomarker for myocardial injury. 1, 3, 4
• Repeat troponin at 3-6 hours if the initial value is normal, because a single normal troponin does not exclude ACS. 1, 3
• Measure vital signs including bilateral arm blood pressures to detect pulse or pressure differentials suggestive of aortic dissection. 1, 3

Focused Physical Examination

• Assess for diaphoresis, tachypnea, pulmonary crackles, S3 gallop, new murmurs, and pericardial friction rub to detect cardiac pathology. 1, 3
• Palpate costochondral junctions to reproduce pain; tenderness suggests costochondritis, which accounts for ~43% of chest pain after cardiac causes are excluded. 3
• Check for epigastric tenderness to support a gastrointestinal diagnosis. 1, 3

Risk Stratification and Disposition

If ECG Shows STEMI or New Ischemic Changes

• Activate emergency medical services immediately for transport to the emergency department; do not delay for troponin results. 1, 3, 4
• Administer chewed aspirin 162-325 mg unless contraindicated. 4

If ECG is Normal but Troponin is Elevated (≥99th Percentile)

• Admit to coronary care unit with continuous cardiac monitoring, dual antiplatelet therapy (aspirin + P2Y12 inhibitor), anticoagulation, and plan urgent coronary angiography. 3

If Both ECG and Serial Troponins are Normal

• Low-risk criteria: normal/nondiagnostic ECG, negative troponin at presentation and 6-12 hours, stable vital signs, no ongoing pain, and absence of heart-failure signs. 1, 3
• Proceed with evaluation for esophageal causes: trial of empiric proton-pump inhibitor (PPI) therapy for suspected GERD is reasonable. 1, 3
• If symptoms persist despite PPI trial, consider upper endoscopy, esophageal function testing, and pH monitoring to exclude esophageal motility disorders. 1, 3
• Outpatient stress testing or coronary CT angiography within 72 hours is recommended given her age (43 years) and hypertension. 3, 5

Critical Pitfalls to Avoid

• Do NOT rely on nitroglycerin response to differentiate cardiac from esophageal chest pain; esophageal spasm also responds to nitroglycerin. 1, 3
• Do NOT dismiss cardiac causes in women based on atypical presentations; women frequently present with throat discomfort, nausea, and fatigue rather than classic chest pain. 1, 2
• Do NOT assume normal vital signs and physical exam exclude ACS; uncomplicated myocardial infarction can present with entirely normal findings. 1, 3
• Do NOT delay transfer to the emergency department if clinical evidence of ACS or other life-threatening causes exists; troponin testing should not postpone transport. 1, 3, 4
• Do NOT use the term "atypical chest pain"; instead describe the presentation as "cardiac," "possibly cardiac," or "non-cardiac" to prevent misinterpretation. 1, 3

Algorithmic Summary

1. Obtain 12-lead ECG within 10 minutes and measure high-sensitivity troponin immediately. 1, 3, 4
2. If ECG shows STEMI or new ischemic changes OR troponin is elevated, activate EMS for immediate emergency department transport. 1, 3, 4
3. If ECG is normal and initial troponin is normal, repeat troponin at 3-6 hours. 1, 3
4. If both troponins are normal, diagnose probable esophageal pathology (GERD or esophageal spasm) and initiate empiric PPI therapy. 1, 3
5. Arrange outpatient stress testing or coronary CT angiography within 72 hours given her cardiovascular risk factors (age 43, hypertension). 3, 5
6. If symptoms persist despite PPI trial, refer for upper endoscopy and esophageal function testing. 1, 3