What is the initial assessment and management for a 24‑year‑old woman presenting with substernal chest pain when respiratory causes are a concern?

Initial Assessment and Management of Substernal Chest Pain with Respiratory Concerns in a 24-Year-Old Woman

Obtain a 12-lead ECG within 10 minutes and draw a high-sensitivity cardiac troponin immediately, even in a young woman with suspected respiratory causes, because life-threatening cardiac conditions must be excluded first. 1, 2

Immediate Life-Threatening Exclusions (First 10 Minutes)

Mandatory Initial Actions

• Acquire and interpret a 12-lead ECG within 10 minutes to identify ST-elevation myocardial infarction, ST-depression, T-wave inversions, or pericarditis patterns (diffuse ST-elevation with PR-depression). 1, 3

• Measure high-sensitivity cardiac troponin immediately because it is the most sensitive and specific biomarker for myocardial injury, and young women are at high risk for underdiagnosis of acute coronary syndrome. 1, 4

• Assess vital signs promptly including heart rate, blood pressure in both arms, respiratory rate, and oxygen saturation to detect tachycardia (>90% of pulmonary embolism patients), pulse differentials (aortic dissection), or hypoxemia. 1, 2, 3

• Perform a focused cardiovascular and pulmonary examination for diaphoresis, tachypnea, unilateral absent breath sounds (pneumothorax), pericardial friction rub (pericarditis), new murmurs, or subcutaneous emphysema (esophageal rupture). 1, 2

Six Life-Threatening Conditions to Rule Out

• Acute coronary syndrome: Women aged 24 can develop ACS, particularly with risk factors (oral contraceptive use, smoking, family history). Typical presentation includes retrosternal pressure building over minutes, but women more frequently present with accompanying symptoms—jaw/neck pain, nausea, fatigue, dyspnea, epigastric discomfort—rather than classic chest pain. 1, 2, 4

• Pulmonary embolism: Sudden dyspnea with pleuritic substernal chest pain that worsens on inspiration; tachycardia occurs in >90% of patients, tachypnea in ~70%. Risk factors include oral contraceptive use, recent immobilization, or surgery. 1, 2, 3

• Tension pneumothorax: Presents with dyspnea, sharp chest pain worsening with inspiration, unilateral absent breath sounds, hyperresonant percussion, tracheal deviation, and hemodynamic instability. 1, 2, 3

• Acute pericarditis: Sharp, pleuritic substernal pain that worsens when lying supine and improves when sitting forward; may have fever and pericardial friction rub. ECG shows diffuse concave ST-elevation with PR-depression. 1, 2, 3

• Aortic dissection: Sudden "ripping" or "tearing" substernal or back pain maximal at onset; pulse differential between extremities (~30% of cases) or systolic BP difference >20 mmHg between arms. 1, 2, 3

• Esophageal rupture (Boerhaave syndrome): Severe substernal pain typically following forceful vomiting; subcutaneous emphysema of neck/chest and concurrent pneumothorax (~20% of cases). 1, 2, 3

Respiratory-Specific Differential Diagnoses

Pneumonia

• Fever with localized, often pleuritic substernal chest pain; physical findings include regional dullness to percussion, egophony, or pleural friction rub. 1, 2, 5

• Obtain chest radiography to evaluate for infiltrate, pleural effusion, or other pulmonary pathology given the respiratory concerns. 4, 5, 6

Pleuritis

• Sharp substernal pain that worsens with deep inspiration; may be viral, bacterial, or autoimmune in etiology. 1, 2, 6

Non-Tension Pneumothorax

• Dyspnea and substernal chest pain worsening with inspiration; unilateral absence of breath sounds and hyperresonant percussion without hemodynamic instability. 1, 2, 6

Special Considerations for Young Women

• Women are at high risk for underdiagnosis of ACS because they frequently present with atypical symptoms; do not dismiss cardiac causes based solely on age (24 years) or atypical presentation. 1, 4

• Actively inquire about accompanying symptoms including jaw/neck pain (10% of women vs 4% of men), nausea/vomiting (32% vs 23%), epigastric discomfort, palpitations, or inter-scapular pain (61.9% vs 54.8%). 4

• Use sex-specific high-sensitivity troponin thresholds (>16 ng/L for women vs >34 ng/L for men); this reclassifies approximately 30% of women as having myocardial injury who would be missed with universal cutoffs. 4

• Assess cardiovascular risk factors including oral contraceptive use, smoking, family history of premature coronary disease, diabetes, hypertension, and hyperlipidemia. 4, 7

Algorithmic Management Pathway

If ECG Shows STEMI or New Ischemic Changes

• Activate emergency medical services immediately and arrange urgent transfer to a facility with 24/7 cardiac catheterization capability; aim for door-to-balloon time <90 minutes. 1, 3

If Initial ECG and Troponin Are Normal

• Repeat high-sensitivity troponin at 1–3 hours (or conventional troponin at 3–6 hours) because a single normal result does not exclude acute coronary syndrome. 1, 3

• Obtain serial ECGs every 15–30 minutes if clinical suspicion remains high to capture evolving ischemic changes. 1, 3

• Consider posterior leads (V7–V9) when intermediate-to-high suspicion for ACS exists and the standard ECG is nondiagnostic. 1, 3

If Both ECG and Serial Troponins Are Normal

• Proceed with respiratory-focused evaluation: chest radiography to assess for pneumonia, pneumothorax, or pleural effusion. 4, 5, 6

• Calculate Wells score for pulmonary embolism if tachycardia, tachypnea, hypoxemia, or risk factors are present; obtain age- and sex-adjusted D-dimer (low-to-intermediate probability) or proceed directly to CT pulmonary angiography (high probability). 1, 3

• Assess for pericarditis: positional pain (worse supine, better leaning forward), pericardial friction rub, and ECG findings of diffuse ST-elevation with PR-depression. 1, 2, 3

Critical Pitfalls to Avoid

• Do not assume young age (24 years) excludes acute coronary syndrome; ACS can occur in adolescents and young adults without traditional risk factors. 3, 4

• Do not rely on nitroglycerin response to differentiate cardiac from non-cardiac chest pain, as esophageal spasm and other conditions may also improve. 1, 2, 3

• Do not dismiss cardiac causes solely because pain is pleuritic or sharp; approximately 13% of patients with pleuritic-type pain have acute myocardial ischemia. 1, 2, 3

• Do not assume a normal physical examination excludes life-threatening disease; uncomplicated myocardial infarction and early pulmonary embolism can present with entirely normal findings. 1, 2, 3

• Do not delay emergency department transfer for additional testing when clinical evidence of ACS or other life-threatening causes exists; arrange urgent EMS transport immediately. 1, 3

• Avoid the term "atypical chest pain"; instead describe presentations as "cardiac," "possibly cardiac," or "non-cardiac" to prevent misinterpretation as benign. 1, 3, 4