Differential Diagnosis for Female Patient with Dizziness and Occasional Chest Pain

Life-Threatening Causes

The American Heart Association recommends considering acute coronary syndrome first in female patients presenting with dizziness and occasional chest pain due to the high risk of underdiagnosis in women 1, 2
Acute coronary syndrome is often underdiagnosed in women because traditional risk assessment tools underestimate their cardiac risk, and women more commonly present with accompanying symptoms including dizziness, nausea, fatigue, shortness of breath, palpitations, and jaw/neck/back pain 1, 3
Aortic dissection presents with sudden-onset ripping chest pain with radiation to the upper or lower back, particularly in hypertensive patients 1, 3
Pulmonary embolism presents with chest pain, dyspnea, and tachycardia in >90% of patients, often with pleuritic pain 3
Pneumothorax causes sudden onset chest pain with dyspnea 3
Esophageal rupture requires immediate recognition despite being less common 2, 3

The American College of Cardiology recommends obtaining a 12-lead ECG to assess for ST-elevation MI, ST depression, or new T-wave inversion within 10 minutes of presentation 3, 4
Measuring cardiac troponin as soon as possible is recommended if acute coronary syndrome is suspected 4, 5
A focused history should emphasize women-specific symptoms, including pain characteristics, accompanying symptoms, and dizziness characteristics 1, 3, 4, 5
A physical examination should include a focused cardiovascular examination, vital signs, cardiac auscultation, lung examination, and assessment for chest wall tenderness 2, 5

The American Heart Association warns against assuming symptoms are noncardiac based on "atypical" presentation, as this terminology is based on male symptom patterns and leads to underdiagnosis in women 2, 4
The American College of Cardiology advises against using nitroglycerin response as a diagnostic criterion for cardiac ischemia 1, 4
Women are at risk for underdiagnosis across all age groups, and cardiac causes should not be dismissed in younger women or those without traditional risk factors 1, 5