What to do if experiencing a myocardial infarction (heart attack) with referred pain in the shoulder?

Immediate Management of Heart Attack with Shoulder Pain

If you are experiencing a heart attack with shoulder pain, call 9-1-1 immediately and chew aspirin 160-325 mg while waiting for the ambulance—do not drive yourself to the hospital. 1

Why Shoulder Pain Matters in Heart Attack

• Shoulder pain is a recognized cardiac symptom that represents referred pain from myocardial ischemia, most commonly radiating to the left arm and shoulder, though right shoulder involvement can occur. 2, 3
• This is NOT an atypical presentation—pain radiation to the arm, shoulder, neck, throat, and jaw are all well-established manifestations of acute coronary syndrome. 2
• Patients with shoulder pain as their primary symptom face higher mortality risk because these presentations are often misdiagnosed as musculoskeletal problems, leading to dangerous treatment delays. 2

Immediate Actions (First 10 Minutes)

Call 9-1-1 first—do not call your doctor or drive yourself: 1

• Approximately 1 in 300 patients who drive themselves to the hospital experience cardiac arrest en route. 1
• Ambulance transport allows for early defibrillation if cardiac arrest occurs, which is most likely within the first hour of symptom onset. 1

Chew aspirin immediately while waiting for EMS: 1, 4

• Dose: 160-325 mg non-enteric coated (chewable or water-soluble for faster absorption). 1, 4
• Aspirin reduces mortality in acute MI and should be given as soon as possible. 4
• Do NOT wait for ECG confirmation before taking aspirin. 4

If you have nitroglycerin prescribed: 1, 5

• Take ONE dose of sublingual nitroglycerin if systolic blood pressure is above 90 mmHg and heart rate is between 50-100 bpm. 4
• Do NOT take additional doses at home—the updated guidelines moved away from the traditional "3 doses over 15 minutes" approach to encourage earlier EMS activation. 5
• If pain persists after one nitroglycerin dose, this confirms the need for immediate 9-1-1 activation. 5

What Happens When EMS Arrives

Paramedics will provide life-saving interventions: 1

• Continuous cardiac monitoring with defibrillator immediately available. 1
• Intravenous access and oxygen administration if you are breathless. 4
• Additional aspirin if not already taken. 1
• Intravenous morphine 4-8 mg for pain relief (with antiemetic to prevent nausea). 1, 4

Hospital Emergency Department Management

ECG within 10 minutes of arrival: 1, 4

• The 12-lead ECG identifies ST-segment elevation ≥1 mm in contiguous leads or new left bundle branch block, which determines whether you need immediate reperfusion therapy. 4
• This is the single most important test to guide treatment decisions. 4

Time-critical reperfusion therapy: 4

• Greatest benefit occurs within the first hour ("golden hour")—35 lives saved per 1,000 patients treated. 4
• Primary percutaneous coronary intervention (PCI) is preferred if available within 90-120 minutes of first medical contact. 5
• Thrombolytic therapy (clot-busting drugs) should be given within 30 minutes if PCI cannot be achieved within 120 minutes. 5
• The target "call to needle time" is 90 minutes maximum. 1

Additional medications administered: 4

• Aspirin 160-325 mg if not already given. 4
• Intravenous heparin to prevent further clot formation. 4
• Beta-blockers, ACE inhibitors, or calcium channel blockers to reduce blood pressure and oxygen demand. 3

High-Risk Features That Require Immediate Action

You are at higher risk if you have: 2, 5

• Known coronary artery disease or previous heart attack. 2
• Diabetes, elderly age, or female sex (these groups more commonly present with shoulder/arm pain rather than classic chest pain). 2
• Pain lasting more than 20 minutes that does not respond to nitroglycerin. 2, 5
• Accompanying symptoms: nausea, sweating, shortness of breath, weakness, or abnormal heart rhythm. 1, 3

Critical Pitfalls to Avoid

Do NOT dismiss shoulder pain as musculoskeletal: 1, 2

• Physical examination contributes almost nothing to diagnosing a heart attack unless shock is present. 1
• Pain affected by palpation, breathing, or movement does NOT rule out cardiac origin—these features can coexist. 1

Do NOT delay calling 9-1-1 to "see if it gets better": 1

• Patient delay from symptom onset to calling for help is the longest component of total treatment delay. 5
• Most cardiac arrests occur within the first hour of symptom onset. 1

Do NOT take multiple nitroglycerin doses at home: 5

• If pain persists or recurs after one dose, this indicates need for emergency evaluation, not more nitroglycerin. 5

Do NOT drive yourself or have family drive you: 1

• Ambulance transport is associated with earlier reperfusion therapy and better outcomes. 1
• Emergency medical technicians can provide life-saving defibrillation if cardiac arrest occurs. 1

Why Every Minute Counts

The benefit of treatment decreases rapidly with time: 4

• First hour: 35 lives saved per 1,000 patients treated. 4
• 7-12 hours: Only 16 lives saved per 1,000 patients treated. 4
• Pre-hospital thrombolysis studies show 23 lives saved per 1,000 per hour of earlier treatment. 1