Evaluation of Exertional Dyspnea and Chest Pain

Immediate Diagnostic Approach

The American Heart Association recommends obtaining a focused history emphasizing accompanying symptoms more common in women with acute coronary syndrome (ACS), including nausea, fatigue, diaphoresis, lightheadedness, and upper abdominal discomfort, as these may be more prominent than chest pain itself in female patients 1, 2, 4
The American College of Cardiology suggests documenting chest pain characteristics: exertional/stress-related symptoms that are pressure-like, dull, squeezing, aching, gripping, or heavy in quality suggest high probability of ischemia 1, 2
Assessing cardiovascular risk factors, including family history, diabetes, hypertension, hyperlipidemia, and smoking history, is crucial in the diagnostic approach 1, 4
A focused cardiovascular examination should be performed to identify signs of heart failure, aortic dissection, or pulmonary embolism 1, 2, 3

The American Heart Association recommends obtaining 12-lead ECG within 10 minutes of presentation to assess for ST-segment elevation MI, ST depression, transient ST-elevation, or new T-wave inversion 1, 2, 5
Measuring cardiac troponin as soon as possible after presentation is recommended if ACS is suspected 1, 2
Obtaining chest radiograph to identify pulmonary causes, cardiomegaly, or pulmonary edema is suggested 6, 5

Acute coronary syndrome/unstable angina is a critical consideration given exertional symptoms and female sex, and the American College of Cardiology recommends excluding this condition promptly 1, 2, 3, 5
Stable angina with progression, exertional chest pain with dyspnea, suggests coronary artery disease 4, 5
Cardiomyopathy or heart failure can present with exertional dyspnea and chest discomfort, according to the American Journal of Respiratory and Critical Care Medicine 7, 8

The American College of Cardiology advises against assuming atypical symptoms exclude ACS in women, as women are at higher risk for underdiagnosis, and accompanying symptoms like fatigue and dyspnea may predominate over chest pain 1, 2, 3, 4
The American Heart Association recommends against using nitroglycerin response as diagnostic criterion, as relief with nitroglycerin occurs with esophageal spasm and other conditions, not just ischemia 4, 5
Delaying cardiac evaluation for less urgent testing is not recommended if ACS is suspected, and immediate ECG and troponin take precedence over other diagnostic considerations 1, 2