Keywords

acute coronary syndrome, aortic dissection, chest pain, differential diagnosis, mitral valve prolapse, panic attack, pericarditis, pneumonia, pulmonary embolism, spontaneous pneumothorax, women

 

Authors

  1. Briggs, Linda A. DNP, ANP-BC, ACNP-BC, FAANP

Abstract

Abstract: The causes of chest pain range from benign sources such as muscle strain to life-threatening diagnoses such as aortic dissection and myocardial infarction. The likelihood and presentations of disorders causing chest pain are different between women and men. This article highlights important features in determining a correct diagnosis.

 

Article Content

Chest pain accounts for almost 6 million ED visits in the United States annually and is a common problem seen in primary care.1 In the general population, the lifetime prevalence of chest pain is 20% to 40%.2 One study reported that 0.7% of patients seen in primary care presented with chest discomfort; 55% were women.3 Although both men and women experience chest pain, the most likely causes can be different based on multiple factors including age, medical history, family history, precipitating conditions, and other predisposing factors. Careful and thorough history taking, physical assessment, and testing are essential for making an accurate diagnosis. This article focuses on the many etiologies of chest discomfort in women.

  
Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Initial assessment

Several life-threatening differential diagnoses must be considered for the complaint of chest pain, including aortic dissection (AD), acute coronary syndrome (ACS), pulmonary embolism, and pneumothorax.4-6 In primary care, urgent care, and ED settings, obtaining an ECG should be a high priority to determine if ST segment deviations, pathologic Q waves, or new left bundle-branch blocks are present, indicating myocardial ischemia, injury, or infarction. The goal should be to obtain and interpret the ECG within 10 minutes of presentation.7

 

In an urgent care or ED setting, obtaining a chest X-ray early in the encounter may also help eliminate competing differentials, such as pneumothorax and pneumonia.8 Furthermore, a widened aortic silhouette is seen on approximately 80% to 90% of chest films of patients with AD.9 Both the ECG and the chest X-ray can be completed while obtaining a history and performing at least a portion of the physical exam. This expedites narrowing the list of differentials and focuses care on any plausible life-threatening diagnosis.

 

Aortic dissection

AD has the highest potential for causing a rapid deterioration in the patient's condition. Fortunately, AD is relatively rare, especially in outpatient settings, and is more frequently seen in men than in women.9,10 In AD, there is a tear (or tears) in the intimal layer, allowing blood to force a separation between the intima and the media of the aorta, creating a false lumen. (See Aortic dissection.) This disruption in the wall of the aorta can jeopardize perfusion in adjacent arteries and organs, leading to potential differences in pulse strength and systolic BP measurements (15 mm Hg or greater) between the affected extremities. It can also lead to syncope, stroke, cardiac ischemia, aortic regurgitation, heart failure, or cardiac tamponade.7,9,11

 

Individuals with AD often present in acute distress and complain of sudden severe "tearing" or sharp pain; the most common location is the chest and/or back.8-11 Patients may describe a "feeling of impending doom."8,9 Hypertension is the most common risk factor for AD, followed by a history of smoking.9,10 Other risk factors include any form of atherosclerosis, collagen disorders such as Marfan syndrome, family history of aortic aneurysms or dissection, age over 60, cocaine abuse, cardiac surgery or intra-aortic procedures, and trauma.11

 

The gold standard diagnostic test for AD is computed tomography (CT) scan with I.V. contrast; however, magnetic resonance imaging provides comparable sensitivity and specificity (100% versus 95% to 100% and 100% versus 94% to 98%, respectively).10 Transesophageal echocardiography also has good sensitivity (86% to 100%) and specificity (90% to 100%) for detecting AD, but results can be dependent on the provider performing the procedure.10 Coronary CT angiography may be useful in distinguishing between pulmonary embolism, ACS, and AD.9

 

Patients with suspected AD should be evaluated immediately by a cardiovascular surgeon.8 Initial management while transporting to or awaiting surgical consultation involves controlling the patient's pain and BP. I.V. opioids are used to treat pain, while I.V. beta-blockers such as metoprolol or an esmolol infusion are used to lower heart rate and BP. The goal is to lower the heart rate to 60 beats/minute and the BP to less than 120 mm Hg systolic.8,12 Other agents such as I.V. labetalol, a nicardipine infusion, or nitroprusside infusion can also be used.8 Further detail regarding the management of patients with AD is beyond the scope of this article.

 

Acute coronary syndrome

ACS is a more frequent life-threatening source of chest discomfort for women. It encompasses unstable angina (new chest discomfort, symptoms occurring at rest or angina that is changing in frequency, provocation, or severity) and acute myocardial infarction (MI).13 The classic presentation for acute MI is chest pain/discomfort (usually described as pressure, tightness, or squeezing) that may radiate to the jaw, neck, shoulders, arm, back, or epigastrum; commonly associated symptoms include dyspnea, nausea, vomiting, diaphoresis, and lightheadedness.14

 

Chest discomfort is the most common symptom expressed by both women and men experiencing acute MI, but women often present with no chest discomfort or with other symptoms.15 Women age 45 or younger are less likely to experience chest discomfort with acute MI; women with an acute MI who do not experience chest pain are at higher risk for death.16 Women may also present with more atypical symptoms of myocardial ischemia, including unusual fatigue, shortness of breath, indigestion, weakness, dizziness, palpitations, or anxiety.14

 

ECG changes and decision making

If acute MI is suspected, an ECG should be obtained immediately. Evidence of ST-segment elevation or a new left bundle-branch block indicates possible acute ST-elevation MI (STEMI). (See Progression of transmural ischemia to infarction.) Women suspected of having STEMI should be sent by an advanced life-support ambulance to the nearest hospital (ideally, a facility capable of performing coronary angioplasty and stenting). When seen in the ED, these patients should be examined immediately by a cardiologist, and the cardiac catheterization team should be notified (if available).17

 

Other ST-segment abnormalities, such as ST depression and/or inverted T waves, may indicate myocardial ischemia. These findings, combined with the patient's presentation and history, will determine the immediacy of further cardiac evaluation. Women with continuing chest pain, severe dyspnea, palpitations, syncope, or near-syncope should be transported to the hospital by emergency medical services. Other concerning findings include significant hyper- or hypotension, pulmonary crackles, the presence of an S3 heart sound, and the systolic murmur associated with mitral regurgitation.7

 

Chest discomfort that occurs with exertion or emotional distress and is relieved by rest or nitroglycerin strongly favors cardiac ischemia and a diagnosis of angina pectoris or unstable angina.7 Relief of discomfort by nitroglycerin is not a definitive test for identifying pain due to cardiac ischemia.18

 

More severe or prolonged symptoms suggest non-STEMI.7 In urgent care, chest pain centers, and ED settings, a cardiac troponin I or cardiac troponin T serum biomarker test can help distinguish acute MI from angina or noncardiac chest pain. Cardiac troponin biomarkers should be obtained at the time of the initial encounter and 3 to 6 hours after symptom onset.19 In primary care settings, troponin results typically cannot be obtained rapidly enough to aid in diagnosis and initial treatment decisions. If there is reasonable suspicion for ACS, the patient should be transported to a hospital or chest pain center for further evaluation and treatment.

 

Risk factors for coronary artery disease

Patient history is another important diagnostic indicator. Women with a previous diagnosis of MI or coronary artery disease (CAD) are more likely to have cardiac-related chest discomfort. Risk factors such as age over 60, smoking, hypertension, diabetes mellitus, dyslipidemia, peripheral arterial disease (PAD), or a positive family history of CAD increase the likelihood of myocardial ischemia.20 Certain risk factors have a greater impact on women than men; for example, women whose parents had an MI before age 60 are at five times the risk of CAD mortality compared with the general population.21 Diabetes mellitus increases women's risk for CAD by three to seven times that of nondiabetic women, compared with a two- to threefold increased risk for men.22

 

A history of pregnancy complications, such as preeclampsia, eclampsia, and gestational hypertension, is a major risk factor for CAD.23 A history of preeclampsia doubles a woman's lifetime risk of MI, stroke, venous thromboembolism, or cardiac death; preeclampsia associated with a premature birth increases a woman's long-term risk for cardiovascular death by more than eight times.24,25 Most important, these events occur in relatively younger women within 5 to 15 years of the index pregnancy.24 Therefore, a young woman with a history of preeclampsia, eclampsia, or gestational hypertension should be considered at risk for CAD even if she has no other risk factors.23

 

Additional diagnostic testing

Because symptoms of CAD are so variable for women, many patients will need to undergo some form of noninvasive testing to definitively rule out this diagnosis. Women with CAD risk factors and symptoms suspicious for angina should be referred to a cardiologist. An individual woman's overall risk for CAD determines the appropriate diagnostic testing. Except for women with a history of pregnancy complications, most premenopausal women without diabetes mellitus are considered at low risk for CAD and should not undergo exercise tolerance testing (ETT) with ECG or other tests.26

 

Symptomatic women in their 50s who are unable to perform some or all of their activities of daily living (ADLs) and women ages 60 to 69 are considered to be at intermediate risk for CAD. Women over age 40 with poorly controlled and/or longstanding diabetes, those with PAD, a history of transient ischemic attack or stroke, and women age 70 and older are at high risk for CAD. Multiple risk factors and functional disability increase risk assessment by one level. For low-intermediate risk women who are able to perform their ADLs, an ETT with ECG is an appropriate test.26 The overall sensitivity and specificity of this test in women are 31% to 71% and 66% to 86%, respectively. While these values are somewhat low compared with other cardiac diagnostic tests, ETT has a reasonably good negative predictive value of 78% for women.20

 

In the past, one of the criticisms of ETT with ECG was that women had a significant number of so-called "false-positive" results. ECG changes or symptoms provoked by ETT that do not correspond with obstructive CAD detected by coronary angiography are no longer considered false positives. They are classified as abnormal and confer an increased risk of ischemic heart disease because recent studies have shown that these women often have microvascular cardiac disease.26

 

The overall accuracy of ETT with ECG to detect CAD can be improved by the addition of the Duke Treadmill Score (DTS). This score is determined by the length of exercise time, the amount of ST-segment change, and appearance of symptoms. Low-risk women with a DTS score of 5 or more have a low annual CAD-related mortality of approximately 0.25%. In contrast, high-risk women with a DTS score of -11 or lower have an annual mortality of 5%. Moderate-risk women with DTS scores of -10 to +4 should undergo stress imaging, such as stress myocardial perfusion imaging or stress echocardiography.26

 

Pulmonary embolism

Another potentially life-threatening diagnosis is pulmonary embolism (PE). Individuals may be asymptomatic, have varying degrees of shortness of breath, or experience circulatory collapse. The most common symptom is dyspnea (82% to 85%); chest pain occurs in only 40% to 49%.27 Tachypnea and tachycardia are other relatively frequent clinical signs. More than 90% of PE cases are associated with lower extremity deep vein thrombosis (DVT).27 Therefore, it is critical to assess for signs of DVT, such as unilateral lower extremity edema.

 

Important clues for increased PE risk include recent travel or immobility; recent major surgery; a history of previous DVT, cancer, estrogen therapy, hematologic diseases (Factor V Leiden mutation, protein C or S deficiencies, polycythemia vera), and pregnancy.27 The American College of Physicians recommends using either the Wells criteria or the revised Geneva score to initially determine the likelihood of PE.28,29

 

If risk is determined to be low, the Pulmonary Embolism Rule-Out Criteria (PERC) should be used to determine whether testing is needed.30 If the patient meets all eight PERC criteria, PE is ruled out and no testing is needed. For patients who do not meet all of the PERC criteria or who are at intermediate risk based on Wells or Geneva scoring, the next step is to obtain a high-sensitivity plasma D-dimer.31 As with cardiac troponin testing, D-dimer results are rarely available in a timely manner in primary care settings. If clinical impression and scoring indicate that a D-dimer should be performed, the patient should be sent to the ED for further evaluation. Patients with a high pretest probability of PE should be sent to the ED to undergo CT pulmonary angiography without obtaining a D-dimer.31

 

Spontaneous pneumothorax

With approximately 20,000 new cases diagnosed in the United States annually, spontaneous pneumothorax is relatively uncommon.32 Primary spontaneous pneumothorax occurs predominantly in tall, thin boys and men between ages 10 and 30 years who are otherwise generally healthy and without preexisting lung disease.33 With primary spontaneous pneumothorax being six times more common in men than in women, it is a rare cause of chest pain in women.32 Secondary spontaneous pneumothorax results from existing pulmonary disorders, such as asthma, chronic obstructive pulmonary disease, or Pneumocystis pneumonia.33

 

The most common symptoms of spontaneous pneumothorax are pleuritic chest pain (90%) and dyspnea (80%). The discomfort is usually confined to the affected side, starting out as sharp pain but becoming dull after a few hours.32 Depending on the size of the pneumothorax, there may be minimal to significant physical findings. If the trapped air occupies more than 15% of the hemithorax, there may be decreased breath sounds and diminished tactile fremitus. Other findings include hypoxemia and acute respiratory alkalosis. When the pneumothorax is severe, there can be a contralateral mediastinal and/or tracheal shift and circulatory collapse.33

 

Visualization of the visceral pleural line on an expiratory anteroposterior chest X-ray is diagnostic for pneumothorax. Bedside thoracic ultrasound may be a more sensitive test.33 Subcutaneous emphysema may be evident on physical exam and/or on the chest X-ray.32 Tension pneumothorax is associated with severe hemodynamic instability and can be life-threatening; it is treated with emergent needle decompression. This is accomplished by inserting an angiocatheter (14 or 16 gauge, 5 cm or longer, and attached to a three-way stopcock and large syringe) in the second intercostal space at the midclavicular line until the air is aspirated; and then the rigid needle is withdrawn, leaving the catheter in place attached to the stopcock and syringe or a Heimlich valve.32,34 Small pneumothoraces (less than 2 cm between the lung and chest wall on X-ray) can be treated conservatively with oxygen, usually administered by non-rebreather mask.32

 

Pneumonia

Another differential diagnosis for chest pain with potentially serious consequences is pneumonia. Determining the most likely cause and quickly initiating appropriate therapy is vital. Assessing the patient's recent environment (community versus foreign country versus long-term care versus hospital) and exposures can provide some important clues. Chest pain associated with pneumonia is pleuritic in nature, increasing with deep inspiration and coughing.

 

Chills, shortness of breath, purulent sputum production, and cough are frequently present. Fever is a common sign of pneumonia except in older adults or immunocompromised patients. On physical exam, the patient may be tachypneic and tachycardic. There may be increased tactile fremitus and dullness to percussion over the affected lung field(s); and crackles, rhonchi, wheezes, egophony, and bronchophony are often heard.4,5

 

A complete blood cell count usually reveals leukocytosis, and a chest X-ray may show opacities in the involved areas. Oxygen saturation measurements may be below normal. Management varies based on the classification of pneumonia as being community-acquired, hospital-acquired, or ventilator-associated. The Infectious Diseases Society of America recommends initial empiric antibiotic treatment with a macrolide such as azithromycin for outpatients with community-acquired pneumonia.35 The most common cause of community-acquired pneumonia is Streptococcus pneumoniae.33 Tools such as CURB-65 and the pneumonia severity index can assist in determining if an outpatient should be hospitalized.36,37

 

Gastrointestinal disorders

Upper gastrointestinal disorders including esophageal spasm, esophagitis, gastroesophageal reflux (GERD), and peptic ulcer disease are common causes of chest pain. The discomfort caused by GERD is usually characterized as retrosternal burning, or heartburn. This is often accompanied by regurgitation of acid or a bitter taste in the mouth. Women more commonly report these symptoms than do men.38 Odynophagia, a sharp substernal pain with swallowing, is often associated with esophagitis. In contrast, the discomfort that occurs with peptic ulcer disease tends to be dull, aching, or gnawing pain located in the epigastric region that is often relieved by food or antacids.39

 

The substernal nature of complaints associated with GERD and esophagitis makes these diagnoses difficult to distinguish from chest discomfort caused by cardiac ischemia. For this reason, an ECG should be obtained to assess for cardiac ischemia. Of note, patients with CAD can have a normal resting ECG. Combining ECG findings with the patient's history of present illness, medical history, medications, and risk factors for the differentials helps narrow the possibilities. Further definitive testing may still be needed to eliminate CAD as the etiology. If peptic ulcer disease is suspected, a urea breath test or fecal antigen test for Helicobacter pylori may help confirm that diagnosis.40

 

Musculoskeletal disorders

Patients with musculoskeletal problems such as costochondritis, Tietze syndrome, muscle strains, and rib fractures may also present with chest pain. Costochondritis accounts for 28% of noncardiac chest pain and is more common in women.41 In costochondritis, there is tenderness to palpation of the junctions between the ribs and the sternum, usually only involving one side of the sternum. The pain can be aching, pressure-like, or sharp and is worsened with movement. There is no swelling or induration of the involved area. Tietze syndrome includes tenderness, erythema, and swelling of only one costochondral junction (usually the second or third rib) and is much less common.42

 

Both costochondritis and Tietze syndrome are self-limited conditions, and conservative treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), stretching exercises, and heat application are helpful.42 Localized tenderness to palpation is also associated with muscle strains and rib fractures. An inciting activity (sports or exercise) or traumatic event is usually the cause.

 

Nonischemic cardiac conditions

Nonischemic cardiac conditions can also cause chest discomfort. Valvular abnormalities and cardiac inflammatory disorders are the most common causes.

 

Mitral valve prolapse (MVP). In women, MVP is fairly common, especially among younger patients.43 Although MVP can be asymptomatic, it may be associated with symptoms such as palpitations and chest discomfort. The chest discomfort that occurs with MVP may mimic angina, but more commonly, it is prolonged and not associated with exertion. There may also be short episodes of sharp stabbing pain at the point of maximal impulse. The classic physical finding associated with MVP is a midsystolic click best heard with the diaphragm along the lower left sternal border. There may be a midsystolic murmur; these sounds may occur alone or together, and maneuvers such as isometric exercise increase their intensity. MVP is generally a benign condition in young women.39 Risk factors for cardiac morbidity in patients with MVP include age 50 years and older, mitral regurgitation, and increased left atrial size.43

  
Figure. Acute perica... - Click to enlarge in new windowFigure. Acute pericarditis

Aortic stenosis (AS). This abnormality, which can cause chest discomfort, is more common in men than in women and tends to occur in older patients (ages 50 to 70). Exertional chest pain is associated primarily with severe AS. Other symptoms of severe AS include near syncope, syncope, exertional dyspnea, and decreased exercise tolerance. Physical findings include a systolic murmur heard loudest at the base; the murmur radiates to the carotid arteries. A thrill (vibration) can sometimes be palpated at the second intercostal space right sternal border. Echocardiography is the best method for confirming this diagnosis.43 Because AS is a chronic, progressive condition, patients suspected of having this disorder should be referred to a cardiologist.

 

Pericarditis. An inflammation of the pericardium, pericarditis typically causes sharp chest pain that worsens with coughing, deep inspiration, and supine positioning; this pain can radiate to the trapezius ridge. The discomfort is often relieved by sitting up or leaning forward. If caused by bacterial infection or an immune response, there may be an associated fever. On physical exam, there may be tachycardia and a pericardial friction rub. The friction rub varies in intensity and sounds like creaking leather.

 

The rub has three components, although frequently, not all are present. At times, the rub may be completely absent. In developed countries, the most common cause of pericarditis is a recent viral illness, although it can be associated with MI, kidney failure, or autoimmune diseases such as systemic lupus erythematosus. The most important initial diagnostic test is an ECG that demonstrates widespread ST elevations and PR-segment depression. (See Acute pericarditis.) Cardiac troponins should be obtained to rule out MI or coexisting myocarditis. High-sensitivity C-reactive protein levels are elevated in about 75% of patients with acute pericarditis.

 

In young women, serum antinuclear antibody testing is suggested to rule out systemic lupus erythematosus as the cause of the pericarditis.44 Refer the patient for an echocardiogram to assess for pericardial effusion and rule out myocarditis with accompanying ventricular dysfunction. Small pericardial effusions are common. If a large effusion is noted, the patient should be hospitalized for monitoring, further diagnostic testing, and treatment. Pericarditis is usually a relatively benign, self-limited disorder. Most commonly, it is treated with NSAIDs or aspirin.44

 

Anxiety disorder

Panic attack. Another common cause of chest discomfort is a panic attack. Patients presenting with this problem often appear anxious and complain of shortness of breath in addition to chest discomfort.45 This presentation overlaps with that of coronary ischemia, so an ECG should be performed. Lowe and colleagues found that asking a single screening question, "In the past 4 weeks, have you had an anxiety attack (suddenly feeling fear or panic)?" had a sensitivity of 93% and a specificity of 78% for detecting panic disorder.46 Other tools for detecting mental health problems, such as the Patient Health Questionnaire, can also be used to effectively aid in making this diagnosis.46

 

Conclusion

The list of potential causes of chest pain in women is long. Taking an expeditious yet methodical diagnostic approach that first rules out life-threatening disorders helps NPs determine the most likely diagnosis. The ECG and chest X-ray are key diagnostic tests that assist in this process. Because of their experience and focus on patient education, NPs can offer a unique contribution to the diagnosis and treatment of women presenting with chest pain. In addition to diagnosis and management, NPs can offer information and reassurance to women presenting with this worrying symptom. This information can aid not only in current management of the problem but also potentially prevent future problems, especially when risk factors for disorders are identified and addressed.

 

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