The most appropriate next step in management is an exercise stress test. Chest pain caused by esophageal disorders can be difficult to distinguish from cardiac chest pain because of the anatomic proximity and common innervation of the esophagus and the heart. Esophageal chest pain is often prolonged, nonexertional, and associated with other esophageal symptoms such as dysphagia, odynophagia, or reflux. The most common cause of noncardiac chest pain is untreated gastroesophageal reflux disease (GERD), followed by motility disorders. Owing to the potentially life-threatening consequences of untreated cardiac chest pain, a cardiac evaluation must be performed and cardiac causes must be ruled out before attributing chest pain to an esophageal cause. In addition, the rationale for evaluating this patient for coronary artery disease is particularly compelling. She has atypical chest pain. Atypical chest pain meets two of the three diagnostic criteria for typical chest pain: substernal in location, provoked by exertion or emotional distress, relieved by rest or nitroglycerin. Taking into account the description of the chest pain, sex, and age, this patient has a 51% pretest probability of coronary artery disease and should be further evaluated with an exercise stress test. If this patient's cardiac evaluation is negative, she should receive an empiric trial of a proton pump inhibitor. If symptoms resolve, this confirms the diagnosis of GERD.

Ambulatory pH testing is used to identify patients with GERD. Esophageal manometry testing will identify an underlying motility disorder of the esophagus. Lastly, upper endoscopy is used to identify mucosal inflammation in the upper gastrointestinal tract. These tests should be performed only after a cardiac condition has been ruled out as the cause of this patient's chest pain.