Diagnostic Approach to Intermittent Chest Pain in Women

Cardiac Causes

The American Heart Association recommends considering cardiac causes first in women presenting with intermittent chest pain due to the high risk of underdiagnosis, with coronary artery disease being the most common cardiac cause 1, 3
Women with acute myocardial infarction more frequently experience pain in the back, neck, and jaw compared to men, and often present with accompanying symptoms including nausea, fatigue, shortness of breath, palpitations, jaw and neck pain, and back pain 4, 5
The American College of Cardiology suggests that chest pain remains the predominant symptom in women with acute coronary syndrome, occurring with equal frequency to men 1, 3
Aortic dissection presents with sudden onset of ripping chest pain, especially with radiation to the upper or lower back, particularly in hypertensive patients, according to the American College of Cardiology 1, 3, 8

The European Society of Cardiology states that pulmonary embolism presents with chest pain, dyspnea, and tachycardia in >90% of patients, often with pain on inspiration 8
Pneumothorax causes sudden onset chest pain with dyspnea, as reported by the European Heart Journal 4, 9

The European Heart Journal notes that gastroesophageal reflux disease and esophageal disorders account for 5-6% of chest pain presentations 9, 5
Esophageal rupture is a life-threatening cause requiring immediate recognition, according to the American Heart Association 2, 10

The European Heart Journal reports that musculoskeletal disorders are the most common cause in primary care settings, accounting for 43% of cases seen by general practitioners 9, 5
Positional chest pain that can be localized to a very limited area is typically nonischemic, as stated by the American College of Cardiology 1, 3, 8

The European Heart Journal states that anxiety, depression, and panic disorders account for 5-11% of chest pain presentations 4, 9, 5
Women may be overrepresented in chest pain due to psychiatric causes, according to the European Heart Journal 4, 5

The American Heart Association recommends obtaining a focused history emphasizing accompanying symptoms more common in women with acute coronary syndrome, such as nausea, vomiting, dyspnea, fatigue, palpitations, jaw/neck/back pain 1, 2, 3
An ECG should be acquired and reviewed within 10 minutes of arrival for any acute chest pain presentation, as suggested by the American College of Cardiology 2, 10
High-sensitivity troponin testing is useful for diagnosing myocardial infarction, but sex-specific thresholds should be used, according to the European Society of Cardiology 4