Differential Diagnosis for Chest Pain in Elderly Females

Life-Threatening Causes

The American College of Cardiology recommends that acute coronary syndrome (ACS) must be the primary consideration in an elderly woman presenting with chest pain, as women ≥75 years are systematically underdiagnosed due to misclassification of symptoms as noncardiac, and age itself is a major independent risk factor for ACS 1, 2.
Acute coronary syndrome frequently presents with accompanying symptoms rather than isolated chest pain in women >75 years, including shortness of breath, syncope, acute delirium, unexplained falls, nausea, fatigue, diaphoresis, palpitations, and epigastric discomfort 1, 2.
Women with hypertension, hyperlipidemia, and previous cardiovascular events have significantly elevated risk, with 66.6% having hypertension and 68.9% having hyperlipidemia in the PROMISE trial 4, 5.
Traditional risk scores underestimate cardiac risk in elderly women by up to 50% 4, 5.
Aortic dissection presents as sudden-onset tearing or ripping chest pain with radiation to upper or lower back 6, 7.

Gastroesophageal reflux disease (GERD) can mimic cardiac symptoms, with epigastric pain that may respond to nitroglycerin, which is not diagnostic for cardiac ischemia 6, 3, 7.
Musculoskeletal/chest wall pain is reproducible with palpation and worsens with specific movements, and positional chest pain is usually nonischemic 6, 7.

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, 7, 8.
Measuring cardiac troponin as soon as possible is recommended if ACS is suspected 3, 7, 8.
A focused history should emphasize accompanying symptoms more common in elderly women, such as jaw/neck pain, back pain, epigastric symptoms, palpitations, nausea, diaphoresis, fatigue, and shortness of breath 1, 4, 5, 3.

Never assume symptoms are noncardiac based on "atypical" presentation, as what is considered "atypical" is based on male symptom patterns 3, 7.
Do not rely on nitroglycerin response as a diagnostic criterion, as esophageal spasm and GERD also respond 6, 3, 7.

Elderly women with diabetes have a higher prevalence of angina but paradoxically lower incidence of obstructive CAD on angiography 1, 2, 4.
Patients >75 years are more likely to have positive stress tests and coronary calcification 2, 5.
A more extensive diagnostic workup is required in older patients due to higher comorbidity burden 2, 5.
Women are less likely to receive timely and appropriate care despite higher symptom burden 4, 5.