At the heart of internal medicine is smart triage: knowing when to worry and when not to worry. Chest pain is one of the most complex scenarios —which is why places like Cottage Urgent Care send all such cases straight to the ER. No exceptions.
A standout article from Raphael et al. published in the Journal of American College of Cardiology 2025 nailed a key issue: heart attacks don’t always follow the textbook script, especially for women. We’re wired to think of them as plaque problems —the classic “plumbing” analogy. Picture an old house’s pipes clogged with calcium buildup. Turn on the faucet full blast, and flow can’t keep up. Or a chunk breaks loose, blocking a downstream branch. Either way, ischemia hits, starving the heart muscle, and the patient presents with the sensation of an elephant standing on the chest. For some reason it’s always an elephant.
But in practice, the real challenge is when blockage stems from non-plaque culprits. The piece highlighted that women are up to 5x more likely to experience a tear on the internal lining of the heart vessel (“SCAD”) which mimics the same physiology. Men’s and women’s arteries differ structurally, and this disparity shows up clinically.
This reinforces 3 major points in my current chest pain algorithm:
- Diagnosis isn’t just about spotting flow issues on an EKG; it’s pinpointing the root cause for tailored treatment. A SCAD tear in a plaque- free vessel doesn’t call for a stent—it demands an entirely different playbook.
- We can’t overlook “atypical” symptoms that pop up more in women, seniors, or diabetics: think nausea, sweating, fatigue, heartburn, or breathlessness. Take a moment to appreciate the complexity of diagnostics here. The diagnostician must create time and space to evaluate the whole story.
- Even gold-standard imaging like a zero-score Calcium CT or Cleerly CT angiogram lowers suspicion—but it never supercedes the patient’s story.
Let me push this further with a thought experiment:
A 55-year-old guy with cutting-edge scans showing zero plaque rolls in with an odd story and normal EKG. In his demo, where plaque reigns, I’d lean non-cardiac. But swap to a 55-year-old diabetic woman with a clean scan just months ago and a compelling narrative? Stop, take it seriously, and dial in.
A wise mentor drilled into me: Medicine’s straightforward when you truly listen. Stay alert —and if something feels off, don’t hesitate to discuss!