A Young Woman With Chest Pain and Normal ECG — Missed Diagnosis Waiting to Happen?

A Deep Dive into Gender Bias, Clinical Blind Spots, and the Realities of chest pain in Women

Introduction: The Classic Scenario That Shouldn’t Be Ignored

A young woman in her late twenties walks into the emergency department.

She says: “I have chest pain.”

The triage notes read:

Vitals: Stable
ECG: Normal
Troponins: Within range
No known risk factors

The reflex response?

“Probably anxiety.”
“She’s too young.”
“Give her something mild and discharge.”

But what if that’s the beginning of a misdiagnosis?

What if behind that stable ECG lies myocardial infarction, spontaneous coronary artery dissection (SCAD), pericarditis, or a pulmonary embolism?

Or even worse: what if we’ve simply been trained—subtly or overtly—to downplay women’s pain when the clinical picture doesn’t immediately scream danger?

1. The Hidden Epidemic: Underdiagnosed chest pain in Young Women

One of the most persistent myths in emergency medicine is that young women don’t get real heart attacks. The data tells a different story.

Cardiovascular disease is the leading cause of death in women worldwide. Women under the age of 55 are seven times more likely to be misdiagnosed with myocardial infarction than their male counterparts. And nearly half of women who experience MI will present with non-classic symptoms—making early recognition even more difficult.

Add to that the unique pathologies disproportionately seen in women—SCAD and MINOCA, for example—and the result is an equation that too often ends in harm:

Atypical symptoms + normal ECG + cognitive bias = diagnostic failure

2. Normal ECG ≠ Normal Heart

The ECG is invaluable, but it’s not infallible. In fact, it may be reassuringly misleading in the exact cases where high suspicion is required.

a. Early MI (especially NSTEMI)
Many women, especially with NSTEMIs, present with non-diagnostic ECGs. Subtle ST depressions, nonspecific T wave changes, or entirely normal tracings are not uncommon. Roughly one-third of women presenting with MI have normal or equivocal ECG findings.

b. Spontaneous Coronary Artery Dissection (SCAD)
Seen in younger, often healthy or postpartum women, SCAD can present with chest pain and an unremarkable ECG. Without high clinical suspicion and coronary imaging, the diagnosis is frequently missed or delayed.

c. Microvascular angina (Cardiac Syndrome X)
This condition, marked by chest pain, normal ECG, and clean coronaries, often affects perimenopausal women and is frequently labeled as anxiety or functional pain. However, myocardial perfusion studies often reveal abnormal results. Ignoring it due to a normal ECG leads to under-treatment and frustration.

If a woman says, “This doesn’t feel right,” and her ECG is normal—it doesn’t mean she’s wrong. It may mean we’re not looking deep enough.

3. The Role of Gender Bias in Medical Decision-Making

Multiple studies highlight gender disparities in cardiac care:

Women presenting with acute coronary syndrome are less likely to receive aspirin, statins, or timely angiography. Their pain is more often labeled “emotional,” “stress-induced,” or “atypical.” Even when clinical presentations are identical, physicians often lean toward benign diagnoses for women and serious ones for men.

This isn’t necessarily due to bad intentions—it’s due to heuristic thinking and entrenched medical training. We’ve learned:

Men + chest pain = rule out MI
Women + chest pain = consider GERD or anxiety

The result? Shorter emergency evaluations, fewer diagnostic tests, and delayed interventions. And too often, young women are sent home only to return in cardiac arrest hours later.

4. Beyond ACS: Other Dangerous Diagnoses Missed in Young Women

A stable ECG and normal vitals can lull clinicians into a false sense of security. But young women with chest pain may be harboring life-threatening conditions that go undetected due to anchoring bias.

1. Pulmonary Embolism (PE)
Even large PEs can present with minimal symptoms. Young women on oral contraceptives, postpartum, or with recent travel or surgery are at increased risk. ECG may be entirely normal or show only sinus tachycardia.

2. Pericarditis or Myopericarditis
Often viral in origin, this causes chest pain that’s positional—worse when lying down, relieved by sitting forward. The ECG may be normal early on or show subtle PR segment changes that are easily overlooked.

3. Aortic Dissection
While rare in young women, connective tissue disorders (e.g., Marfan, Ehlers-Danlos) increase the risk. When missed, outcomes are devastating.

4. GERD masking concurrent ischemia
It’s not uncommon for ischemic chest pain to mimic reflux. Don’t let a patient’s history of indigestion blind you to the possibility of cardiac ischemia.

5. Panic attacks with underlying cardiac disease
Anxiety can coexist with real pathology. Just because a patient appears anxious doesn’t exclude myocardial infarction.

5. What Does “Atypical chest pain” Even Mean?

The term “atypical chest pain” has become dangerously misleading. In many clinical settings, it’s interpreted as “not cardiac,” when in fact, women’s so-called atypical symptoms are biologically typical for them.

Common presentations in women include:

Fatigue
Dyspnea
Nausea or vomiting
Jaw, neck, or shoulder pain
Lightheadedness
Epigastric pain or discomfort

Labeling these as “atypical” discourages further investigation and reinforces the stereotype that women’s symptoms are vague or exaggerated.

6. Missed Diagnosis in Action: Real-Life Tragedies

These are not rare exceptions. They are unfortunately common.

• A 32-year-old woman with SCAD was diagnosed with indigestion and discharged. She died at home hours later.
  
  
• A 29-year-old postpartum patient presented with shortness of breath. Treated for “panic attack,” she collapsed in the hospital parking lot with massive PE.
  
  
• A 35-year-old marathon runner with sharp chest pain was told she was “too fit” to be sick. She died from aortic dissection en route to another hospital.
  

These are not anecdotes. They are systemic failures rooted in cognitive bias, poor education about sex-specific presentations, and misplaced clinical confidence.

7. How Can Doctors Do Better?

There are practical, immediate steps every clinician can take to avoid falling into these traps.

✅ Take the history seriously
Go beyond “sharp or dull.” Ask about exertional triggers, positional changes, associated symptoms. Listen with curiosity, not just pattern recognition.

✅ Don’t let a normal ECG stop you
It’s a tool, not a verdict. Serial ECGs, troponins, bedside echo, or cardiology consults can reveal evolving pathology.

✅ Use clinical scores—but don’t over-rely
Wells, HEART, and PERC are useful guides—but they can’t replace judgment, especially in young women with non-classic symptoms.

✅ Trust the patient’s instincts
If she says, “Something’s wrong,” it likely is. Even if the numbers and imaging aren’t alarming—keep looking.

✅ Factor in sex-specific risks
Pregnancy, hormonal therapy, autoimmune disease, migraine with aura—all are relevant to cardiovascular risk.

✅ Document your reasoning
If you decide to discharge, note why you believe it’s safe. This protects the patient—and yourself—should things change.

8. The Role of Medical Education

Medical education must evolve to address this gap. Gender-specific training in cardiovascular disease is often lacking in medical school and residency curricula.

Simulation scenarios should include women with non-classic chest pain. Continuing education should emphasize SCAD, MINOCA, and microvascular disease. Awareness needs to be built early—and reinforced often.

Doctors don’t miss these diagnoses because they’re negligent. They miss them because they were never trained to consider them.

9. What Patients Can Teach Us

Young women often say:

“I knew something was wrong, but they sent me home.”
“They said I was too young for anything serious.”
“They chalked it up to stress.”

Re-presentation should be treated as a clinical red flag—not as attention-seeking or emotional instability. It’s a signal that we may have missed something.

When objective data conflicts with the patient’s subjective experience—pause. Listen. Reassess.

10. Final Thoughts: Do Not Be Reassured by a Normal ECG

A normal ECG does not mean the heart is fine. It simply means we haven't found the problem—yet.

chest pain in a young woman with no obvious red flags deserves the same diligence as in a 65-year-old man with diabetes and hypertension. Not because the risk is equal, but because the consequences of missing it can be catastrophic.

Taking her seriously doesn’t mean over-investigating. It means acknowledging that our tools and training have blind spots—and choosing to look past them.

When you listen to her words as carefully as you read her labs, you reduce the risk of tragedy. And more often than not, that vigilance will save lives.