What are the treatment options for arm pain radiating to the chest?

Pain in Arm Radiating to Chest: Treatment Approach

This presentation requires immediate emergency evaluation as it represents a potential acute coronary syndrome (ACS) or other life-threatening condition—call emergency medical services (EMS) immediately and do not attempt self-transport. 1

Immediate Actions (First 10 Minutes)

The priority is rapid recognition and treatment of potentially fatal conditions, particularly ACS, which can present with arm pain radiating to the chest.

• Call 9-1-1 immediately rather than transporting the patient yourself, as EMS can initiate treatment en route and provide continuous monitoring 1, 2
• Administer aspirin 325 mg (one adult tablet) or 2-4 baby aspirins (81 mg each), chewed and swallowed, if no allergy or recent bleeding and symptoms suggest cardiac origin 1, 2
• Place patient on continuous cardiac monitoring with defibrillation capability immediately available 1, 2
• Obtain 12-lead ECG within 10 minutes of arrival to emergency department to identify ST-elevation myocardial infarction (STEMI), ST-depression, T-wave inversions, or new left bundle branch block 1, 2
• Measure cardiac troponin as soon as possible after presentation 1, 2

Critical History Elements to Obtain

While obtaining history, do not delay entry into the ACS protocol. 1

Pain Characteristics That Increase Cardiac Likelihood:

• Central/substernal pressure, tightness, heaviness, crushing, or burning sensation 1, 3
• Pain radiating to neck, jaw, shoulders, back, or one or both arms—particularly radiation to the right arm increases likelihood of ACS (likelihood ratio 2.9) 1, 4
• Pain radiating to both arms or shoulders (likelihood ratio 4.07 for AMI) 5
• Duration >20 minutes suggests acute myocardial infarction 6
• Exertional pain (likelihood ratio 2.35 for AMI, 2.06 for ACS) 5

Associated Symptoms That Elevate Risk:

• Diaphoresis (sweating) 1, 3
• Nausea and/or vomiting 1, 3
• Dyspnea (shortness of breath) 1, 3
• Lightheadedness, dizziness, or presyncope 1
• Unexplained indigestion or epigastric pain 1, 3

Risk Factors to Assess:

• Prior coronary artery disease, percutaneous coronary intervention (PCI), or coronary artery bypass graft (CABG) 1
• Smoking, hyperlipidemia, hypertension, diabetes mellitus, family history 1, 3
• Cocaine or methamphetamine use 1

Special Population Considerations

Women:

• Women present more frequently with atypical symptoms including nausea, back pain, dizziness, and palpitations in addition to chest pain 1, 3
• Women are at risk for underdiagnosis and potential cardiac causes must always be considered 1, 3
• Women have higher rates of non-classical mechanisms including plaque erosion, microvascular dysfunction, coronary vasospasm, and spontaneous coronary artery dissection 3

Diabetic Patients:

• May have atypical presentations due to autonomic dysfunction, including minimal or absent pain 1, 3

Elderly Patients:

• May present with generalized weakness, stroke, syncope, or altered mental status rather than typical chest pain 1, 3

ECG-Based Treatment Pathways

If ST-Elevation Present:

• Immediate reperfusion therapy (primary PCI preferred or fibrinolysis if PCI unavailable) per STEMI protocols 2
• Activate cardiac catheterization laboratory immediately 2

If ST-Depression, T-Wave Inversions, or Normal ECG:

• Initiate medical therapy immediately while awaiting troponin results 2
• Aspirin 75-150 mg daily (if not already given) 2
• Clopidogrel loading dose 2
• Low molecular weight heparin (LMWH) or unfractionated heparin 2
• Beta-blocker (e.g., metoprolol) unless contraindicated 2

Risk Stratification Based on Troponin Results

High-Risk Features (Require Invasive Strategy):

• Elevated troponin levels 2
• Recurrent ischemia despite medical therapy 2
• Hemodynamic instability 2
• Major arrhythmias 2
• Diabetes mellitus 2
• Hospital admission for invasive strategy within 24-48 hours 2

Low-Risk Features:

• Normal troponin at presentation and 6-12 hours later 2
• No recurrent chest pain during observation 2
• No ECG changes 2
• Hemodynamically stable 2
• Proceed with stress testing (exercise stress test, stress echocardiography, or coronary CT angiography) before discharge or as outpatient 2

Alternative Life-Threatening Diagnoses to Consider

Acute Aortic Syndrome:

• Sudden onset of "ripping" pain radiating to the back is highly suspicious 7
• Check for pulse differentials between extremities (present in 30% of aortic dissections) 7
• "Worst pain of my life" description, especially with hypertension or known aortic valve disease 7
• Requires immediate CT angiography of chest with IV contrast 7, 2

Pulmonary Embolism:

• Pleuritic chest pain with dyspnea and tachycardia 2
• Requires CT pulmonary angiography 2

Common Pitfalls to Avoid

• Do not use nitroglycerin response as a diagnostic criterion—esophageal spasm and other conditions can respond similarly 1, 3
• Do not assume musculoskeletal cause without cardiac workup—approximately 10-50% of chest pain is musculoskeletal, but this is a diagnosis of exclusion 8
• Do not dismiss atypical presentations, particularly in women, diabetics, and elderly patients 1, 3
• Do not delay ECG or troponin measurement to complete detailed history 1
• Absence of chest wall tenderness does not rule out cardiac cause—chest wall tenderness has likelihood ratio of only 0.3 for excluding AMI 5

Non-Cardiac Causes (After Cardiac Workup Negative)

If cardiac evaluation is definitively negative:

• Musculoskeletal disorders (costochondritis, fibromyalgia)—treat with physiotherapy, manual therapy, transcutaneous electrical stimulation, and stabilization exercises 8
• Gastroesophageal reflux disease 2
• Treat underlying condition and avoid empiric cardiac medications 2