What are the next steps for a patient who had chest pain radiating to the left arm with a tingling sensation in the fingertips, a heavy arm, and difficulty raising it, but is now asymptomatic?

Immediate Emergency Department Evaluation Required

This patient requires immediate emergency department evaluation with ECG within 10 minutes and cardiac troponin measurement, even though currently asymptomatic, because the preceding symptoms are highly concerning for acute coronary syndrome (ACS) that may have spontaneously resolved or progressed to complete occlusion. 1, 2

Critical Action Steps

Immediate Transport and Triage

• Activate 9-1-1 for emergency medical services (EMS) transport to the nearest emergency department immediately 1
• The patient should NOT drive themselves or delay seeking care despite current symptom resolution 1
• Classic presentation of chest pain radiating to left arm with tingling, heaviness, and difficulty raising the arm has high likelihood for ACS, with this constellation of symptoms being highly specific 2, 3

First 10 Minutes in Emergency Department

Obtain 12-lead ECG within 10 minutes of arrival to identify:

• ST-elevation myocardial infarction (STEMI) requiring immediate reperfusion 1, 2
• ST-segment depression or T-wave inversions indicating NSTEMI/unstable angina 1, 2
• Normal ECG does NOT rule out ACS—up to 7.7 times more likely to be inappropriately discharged with normal ECG, leading to increased mortality 4

Measure cardiac troponin immediately upon presentation 1, 2:

• Elevated troponin with typical symptoms indicates NSTEMI requiring admission 2, 3
• Initial negative troponin does NOT exclude ACS—serial measurements at 2 hours are required 5, 6

Physical Examination Priorities

Focus cardiovascular examination on high-risk features 1, 2:

• Diaphoresis has 95% specificity (likelihood ratio 5.18) for ACS 2, 3
• Check for pulse differentials between extremities (present in 30% of aortic dissections) 1, 7
• Assess for signs of heart failure: tachycardia, tachypnea, crackles, S3 gallop, new murmurs 1
• Hypotension or hemodynamic instability indicates high-risk presentation 1

Why Asymptomatic Status Does NOT Change Management

Critical Pitfall to Avoid

Pain resolution does NOT exclude ongoing myocardial infarction or indicate lower risk 2:

• Symptoms lasting "several hours" followed by resolution may represent:
  • Complete coronary occlusion with infarction already established
  • Intermittent coronary occlusion (unstable angina)
  • Spontaneous reperfusion after partial infarction
• The 2.1% of acute MI patients and 2.3% of unstable angina patients who are inappropriately discharged from emergency departments have nearly double the mortality risk (risk-adjusted mortality ratio 1.9) 4

Serial Monitoring Required

If initial ECG is nondiagnostic, perform serial ECGs to detect evolving ischemic changes, especially given the high clinical suspicion from the preceding symptoms 1, 2:

• Repeat ECG if symptoms recur or clinical condition changes 1
• Obtain second troponin at 2 hours using high-sensitivity assay protocols 5, 6

Disposition Decision Algorithm

Admit to Hospital If:

• Troponin elevated OR ECG shows ischemic changes → Immediate admission for ACS management per cardiology protocols 2, 3
• Ongoing chest pain or hemodynamic instability → Coronary care unit admission 1
• High-risk features present: age >65, diabetes, prior CAD, heart failure signs 1

Observation/Further Testing If:

• Initial troponin negative AND ECG nondiagnostic BUT high clinical suspicion based on symptom description 2
• Apply 0/2-hour algorithm: second troponin at 2 hours with specific cutoffs for rule-out (sensitivity 98-99%) 5, 6
• Consider stress testing or coronary CT angiography before discharge only if serial troponins negative 1

Never Discharge Without:

• At minimum, two negative troponins separated by 2 hours using high-sensitivity assay 5, 6
• Nonischemic ECG findings 1, 2
• Alternative diagnosis clearly established 1

Additional Differential Considerations

While cardiac evaluation is priority, brief assessment for other life-threatening causes 1, 3:

• Aortic dissection: Sudden tearing pain, pulse differential, mediastinal widening on chest X-ray 1, 7
• Pulmonary embolism: Dyspnea, tachycardia, pleuritic pain 1, 7
• Musculoskeletal pain would be reproducible with palpation and movement—but this diagnosis requires cardiac exclusion first 2

The arm symptoms (tingling, heaviness, difficulty raising) combined with preceding chest pain create a clinical picture that mandates full cardiac evaluation regardless of current symptom status. 2, 3