What is the management approach for arm and chest pressure with differential diagnosis?

Management of Arm and Chest Pressure: Differential Diagnosis and Approach

Patients presenting with arm and chest pressure require immediate evaluation for acute coronary syndrome (ACS), which includes unstable angina and non-ST-elevation myocardial infarction (NSTEMI), as this represents a life-threatening emergency requiring rapid diagnosis and treatment within minutes. 1

Immediate Triage and Recognition

Key symptoms requiring immediate assessment include: 1

• Chest pain, pressure, tightness, or heaviness radiating to neck, jaw, shoulders, back, or one or both arms
• Central/substernal compression or crushing chest pain
• Associated diaphoresis, dyspnea, nausea, or vomiting
• Unexplained indigestion or epigastric pain

Obtain a stat ECG within 10 minutes of arrival to assess for cardiac ischemia or injury. 1

Critical Differential Diagnoses

The differential diagnosis for arm and chest pressure includes life-threatening conditions that require immediate hospital care: 1

Cardiovascular Causes

• Acute Coronary Syndrome (UA/NSTEMI/STEMI): Most common presentation is pressure-type chest pain at rest or with minimal exertion lasting ≥10 minutes, radiating to arms, neck, or jaw 1
• Aortic Dissection: Suggested by back pain, unequal pulse volume, ≥15 mm Hg blood pressure difference between arms, or aortic regurgitation murmur 1
• Pulmonary Embolism: Presents with chest pain, dyspnea, syncope, or hemoptysis; symptoms are highly non-specific 2
• Acute Pericarditis: Identified by pericardial friction rub 1

Other Life-Threatening Causes

• Pneumothorax: Acute dyspnea, pleuritic chest pain, and differential breath sounds 1
• Hypertensive Emergency: High blood pressure with acute target organ damage (acute MI, unstable angina, acute pulmonary edema) 1, 3

Diagnostic Workup Algorithm

Step 1: Initial Assessment (First 10 Minutes)

• 12-lead ECG immediately 1
  • ST-segment depression or transient ST-elevation indicates NSTE-ACS 1
  • Normal ECG does not exclude ACS (occurs in 1-6% of ACS patients) 1
  • Consider posterior leads (V7-V9) if initial ECG normal but suspicion high 1

Step 2: Risk Stratification

Use validated risk scores incorporating clinical findings and first troponin: 4

• HEART score (0-10): High-risk range 7-10 (LR 13 for ACS diagnosis) 4
• TIMI score (0-7): High-risk range 5-7 (LR 6.8 for ACS diagnosis) 4
• Low-risk HEART score (0-3) has LR 0.20 for excluding ACS 4

Step 3: Cardiac Biomarkers

• Cardiac troponins are most sensitive and specific for NSTE-ACS 1
• Rise within hours of symptom onset and remain elevated for days 1
• Negative high-sensitivity troponin on admission has ≥99% negative predictive value for MI 1

Step 4: Additional Diagnostic Studies

Based on clinical presentation: 1

• Chest X-ray: Identifies pulmonary causes, widened mediastinum (aortic dissection)
• CT chest with IV contrast: For suspected aortic dissection or pulmonary embolism
• Echocardiography: Assess cardiac structure/function if heart failure suspected
• D-dimer and CT pulmonary angiography: If pulmonary embolism suspected 2

High-Risk Clinical Features

Findings most suggestive of ACS: 4

• Prior abnormal stress test (specificity 96%, LR 3.1)
• Peripheral arterial disease (specificity 97%, LR 2.7)
• Pain radiation to both arms (specificity 96%, LR 2.6)
• ST-segment depression on ECG (specificity 95%, LR 5.3)

Risk factors increasing ACS probability: 1

• Older age, male sex, family history of CAD
• Diabetes mellitus, renal insufficiency
• Prior MI or coronary revascularization
• Peripheral arterial disease

Atypical Presentations Requiring High Suspicion

Certain populations present atypically more frequently: 1

• Women: More frequent atypical chest pain 1
• Elderly patients (≥75 years): Generalized weakness, syncope, change in mental status 1
• Diabetic patients: Atypical presentations due to autonomic dysfunction 1
• Atypical symptoms to recognize: Epigastric pain, indigestion, stabbing/pleuritic pain, increasing dyspnea without chest pain 1

Immediate Management

For Suspected ACS

While completing diagnostic workup: 1, 5

• Aspirin 250-500 mg immediately (chewable or water-soluble) 1
• Sublingual nitroglycerin if no bradycardia or hypotension (onset 1-3 minutes, peak effect 5 minutes) 5
• Opiates for pain and anxiety relief 1
• Continuous monitoring with repeat ECGs at 15-30 minute intervals if initial ECG nondiagnostic 1

For Hypertensive Emergency

If blood pressure severely elevated with target organ damage: 1

• Controlled BP reduction with IV antihypertensives
• Avoid rapid BP lowering to prevent cardiovascular complications
• Short-acting nifedipine should NOT be used 1

Common Pitfalls to Avoid

• Do not rely on normal ECG alone to exclude ACS—1-6% of ACS patients have normal initial ECG 1
• Do not dismiss atypical presentations in women, elderly, or diabetic patients 1
• Do not delay aspirin administration while awaiting diagnostic confirmation 1
• Do not use clinical examination alone for diagnosis—physical exam in NSTE-ACS can be completely normal 1
• Do not assume musculoskeletal cause based on chest wall tenderness—this does not exclude ACS 4
• Recognize that pain affected by palpation, breathing, or body position provides highest diagnostic information AGAINST angina, but does not definitively exclude it 1