These symptoms disrupted her work as a postal worker and brought her to the second emergency department for evaluation.

Over the next week, patient’s symptoms worsened with chest pain radiating down right arm, associated with profound fatigue, dizziness, lightheadedness, tingling in the jaw. She was discharged home, with a diagnosis of non-cardiac chest pain. On this basis she underwent a coronary angiography at the local hospital that revealed no obstructive coronary disease. On the basis of her abnormal stress echocardiogram she also underwent stress perfusion imaging that showed possible anterior ischemia – again in the setting of her LBBB. Exercise was stopped secondary to fatigue, and the only concerning finding was that she had septal hypokinesis that was read as possible ischemia versus a consequence of her LBBB. Her cardiac biomarkers were negative, and she underwent a stress echocardiogram during which she exercised for 6 minutes on a Bruce protocol, achieving 7.1 metabolic equivalents (METS), and had normal left ventricular chamber size diminution and a normal baseline ejection fraction (~65 percent). She had a transient left bundle branch block (LBBB) on her electrocardiogram and was worked up for acute coronary syndrome. Patient reported being admitted to a nearby hospital with similar symptoms a month earlier. She described pressure in the sternal area of her chest, constant, 7/10, radiating to her back, her jaw and her right arm. History: A 37-year old female with history of migraine and recent diagnosis of hypertension presented to the ED complaining of chest pressure and dyspnea on exertion for two weeks prior to presentation. Future work is needed to better define the epidemiological, clinical, biological, and genetic correlates of microvascular dysfunction in these patients. Clinicians should consider additional diagnostics to routinely screen for non-CAD related causes of angina in patients with recurrent chest pain.

Non-CAD related angina is associated with persistent chest pain causing poor function, quality of life, and recidivism. Additional causes include coronary artery spasm, coronary artery dissection, coronary artery endothelial dysfunction and myocardial bridging. Once coronary artery disease (CAD) is ruled out with standard protocols, microvascular dysfunction is perhaps the most prevalent but under-diagnosed cause of non-CAD related angina in ED patients. This case-based perspective describes the different sex-specific causes of angina seen in ED patients. While a cardinal symptom of acute coronary syndrome (ACS), multiple emergent and non-emergent causes can attribute to chest pain. Emergency departments (ED) in the United States see over eight million cases of chest pain annually.

Sudden chest pain in women