What is the appropriate diagnosis and treatment for a patient presenting with left neck soreness, headache, shortness of breath, and fatigue?

Immediate Evaluation for Acute Coronary Syndrome

This patient requires immediate evaluation for acute coronary syndrome (ACS), as the combination of left neck soreness, headache, shortness of breath, and fatigue represents a potentially life-threatening cardiac presentation that demands urgent 12-lead ECG and cardiac biomarker testing. 1, 2

Critical Recognition of Atypical ACS Presentation

• Acute coronary syndrome frequently presents without typical chest pain, particularly in women, elderly patients, and those with diabetes, manifesting instead as isolated neck pain, shoulder discomfort, dyspnea, or fatigue. 1, 2

• The American Heart Association emphasizes that neck pain combined with shortness of breath is a particularly worrisome symptom constellation, with dyspnea alone carrying more than twice the risk of death compared to typical angina in patients with cardiac disease. 1

• One-third of confirmed myocardial infarctions present without chest discomfort, and these patients experience significantly higher in-hospital mortality (23.3% vs 9.3%) due to delayed recognition and treatment. 1

Immediate Diagnostic Algorithm

Step 1: Emergency Medical Services Activation

• The patient should call 9-1-1 immediately and be transported by ambulance rather than self-transport, as symptoms lasting more than 5 minutes without improvement require emergency evaluation. 1

Step 2: Obtain 12-Lead ECG Within Minutes

• A 12-lead ECG must be obtained immediately at first medical contact, as ST-segment depression as little as 0.05 mV predicts adverse outcomes and guides reperfusion therapy decisions. 1
• The ECG should be repeated if symptoms persist or worsen, as early recordings may be equivocal even in proven infarction. 1

Step 3: Cardiac Biomarker Testing

• Draw troponin and CK-MB immediately, but do not delay treatment while awaiting results if ECG shows ST-segment elevation or new left bundle branch block. 1, 2

Step 4: Immediate Aspirin Administration

• Administer 162-325 mg aspirin (chewed, non-enteric coated) unless contraindicated, as this should occur in the prehospital setting. 1

Alternative Life-Threatening Diagnoses to Exclude

Aortic Dissection Assessment

• Evaluate for sudden onset, tearing quality pain, and radiation to the interscapular region, which would require immediate imaging. 2

Pulmonary Embolism Consideration

• The combination of dyspnea and fatigue warrants assessment for PE risk factors and consideration of D-dimer testing. 2

Vertebral Artery Dissection

• Neck pain with headache raises concern for vertebral artery dissection, particularly if there is recent trauma or sudden onset. 2, 3

Red Flag Assessment for Non-Cardiac Etiologies

If cardiac workup is negative, the following red flags require urgent investigation:

• Fever, elevated inflammatory markers (ESR, CRP), or constitutional symptoms suggest infection (meningitis, epidural abscess) or inflammatory conditions requiring urgent MRI cervical spine without contrast. 2, 3, 4

• Neurologic deficits or altered mental status mandate immediate neuroimaging to exclude intracranial pathology or spinal cord compression. 2, 3

• Neck stiffness with headache requires lumbar puncture consideration after imaging to exclude meningitis or subarachnoid hemorrhage. 5, 6

Critical Pitfalls to Avoid

• Never rely on nitroglycerin response to exclude cardiac ischemia, as musculoskeletal conditions may also respond to vasodilators. 2

• Do not assume symptoms are musculoskeletal without first excluding life-threatening cardiac and vascular etiologies through ECG and biomarkers. 1, 2

• Avoid telephone-only evaluation—this patient requires in-person assessment with ECG capability and biomarker testing available. 1

• Do not delay evaluation based on age or perceived low risk, as silent MI patients have 2.2 times higher mortality when diagnosis is delayed. 1

Subsequent Management Based on Initial Findings

If ACS is confirmed:

• Initiate reperfusion therapy immediately (PCI or fibrinolysis depending on ST-elevation presence and time from symptom onset). 1
• Administer antiplatelet therapy, anticoagulation, beta-blockers, and statins per ACS protocols. 1

If cardiac evaluation is negative:

• Proceed with MRI cervical spine without contrast if red flags are present (elevated inflammatory markers, neurologic symptoms, constitutional symptoms). 1, 2, 3, 4
• Consider plain radiographs only if no red flags exist and mechanical neck pain is suspected. 1, 2
• Most mechanical neck pain resolves with conservative management (NSAIDs, physical therapy, activity modification) after serious pathology is excluded. 1, 2, 4