What is the suggested course of action for a patient with a history of asthma, depression, and anemia who presents with heart palpitations, recent chest pain, and left arm tingling, but is unable to afford an electrocardiogram (EKG) at this time?

Immediate Emergency Department Referral Required

This patient must be transported immediately to the Emergency Department by ambulance (EMS) for urgent evaluation—delaying transfer for an EKG or other diagnostic testing in the office setting is contraindicated and potentially harmful. 1

Why This Patient Requires Urgent ED Transfer

This patient presents with high-risk features for acute coronary syndrome (ACS) that mandate immediate emergency evaluation:

• Chest pain with left arm tingling is a classic presentation for ACS, representing chest or left arm discomfort as the chief symptom 1
• Prolonged chest pain lasting days with recurrent episodes, including waking from sleep with chest pain and dyspnea, suggests ongoing ischemia 1
• Inability to catch breath during chest pain indicates potential hemodynamic compromise or heart failure 1
• Heart palpitations combined with chest pain raises concern for arrhythmias complicating ACS 1

Critical Guideline-Based Actions

Immediate Transport by EMS (Not Personal Vehicle)

Call 9-1-1 immediately to activate EMS for this patient. 1 Transport by ambulance provides:

• Pre-hospital ECG acquisition within 5-10 minutes, which reduces mortality and in-hospital delay time 1, 2
• Trained personnel who can administer aspirin, provide defibrillation, and manage complications en route 1, 2
• Ability to activate the cardiac catheterization lab before arrival if STEMI is identified 1, 2

While Awaiting EMS Arrival

Administer aspirin 162-325 mg (chewed, not swallowed) immediately unless contraindicated (active GI bleeding or known aspirin allergy). 1, 2 This intervention:

• Reduces mortality when given early in ACS 1
• Can be given by emergency medical dispatchers via phone instruction or by office staff 1
• Should not delay calling 9-1-1 1

Why Office-Based Evaluation Is Inappropriate

The 2021 ACC/AHA guidelines explicitly state (Class 3: Harm recommendation) that delayed transfer to the ED for troponin or other diagnostic testing should be avoided in patients with suspected ACS initially evaluated in the office setting. 1

The rationale includes:

• Time is myocardium: Every hour of delay increases mortality—thrombolytic therapy saves 35 lives per 1000 when given within the first hour versus only 16 lives per 1000 when given 7-12 hours after symptom onset 2
• Office settings lack critical capabilities: Cardiac troponin measurement, serial ECGs, continuous cardiac monitoring, and immediate access to reperfusion therapy are unavailable 1
• This patient's symptoms have been ongoing for days, increasing the risk that acute MI has already occurred or is evolving 1

Risk Stratification: This Patient Is High-Risk

According to ACC/AHA risk stratification criteria, this patient has multiple high-risk features: 1

• Prolonged ongoing rest pain (chest pain lasting days with recurrent episodes) 1
• Chest or left arm pain as chief symptom 1
• Associated dyspnea ("could not catch breath") 1
• Accelerating tempo of symptoms (woke up with chest pain the night prior) 1

High-risk patients require immediate ED evaluation with ECG within 10 minutes of arrival and troponin measurement as soon as possible. 1

What Will Happen in the Emergency Department

Once in the ED, this patient will receive: 1

• 12-lead ECG within 10 minutes to identify STEMI or other ischemic changes 1
• Serial cardiac troponin measurements (preferably high-sensitivity troponin) to detect myocardial injury 1
• Serial ECGs if initial ECG is nondiagnostic but clinical suspicion remains high 1
• Continuous cardiac monitoring for arrhythmias 1
• Immediate reperfusion therapy if STEMI is identified (door-to-needle time <30 minutes for thrombolysis or first medical contact to balloon time <90 minutes for primary PCI) 2

Addressing the Cost Concern

While the patient's inability to afford an EKG is noted, this concern cannot override the immediate life-threatening risk. 1

• Many hospitals have financial assistance programs and charity care for emergency services 1
• The Emergency Medical Treatment and Labor Act (EMTALA) requires emergency departments to provide stabilizing treatment regardless of ability to pay 1
• The cost of delayed diagnosis of ACS—including death, permanent myocardial damage, heart failure, and disability—far exceeds the cost of emergency evaluation 1, 2

Common Pitfalls to Avoid

Do not assume this is asthma-related chest pain despite the patient's asthma history. While chest pain can occur with asthma exacerbations 3, 4, 5, this patient's presentation with:

• Left arm tingling 1
• Prolonged duration over days 1
• Nocturnal awakening with dyspnea 1
• Palpitations 1

...is far more consistent with ACS than asthma. 1

Do not attempt to "rule out" cardiac causes with a trial of bronchodilators in the office setting. 1 While some chest pain may respond to asthma medications 4, this approach delays critical evaluation and is contraindicated when ACS features are present. 1

Do not rely on the patient's depression or anxiety history to attribute symptoms to panic disorder. 6 While chest pain and palpitations can occur with panic, the presence of left arm tingling and prolonged symptoms over days makes ACS the priority diagnosis that must be excluded first. 1

Summary Action Plan

1. Call 9-1-1 immediately 1, 2
2. Give aspirin 162-325 mg (chewed) now unless contraindicated 1, 2
3. Keep patient at rest and monitor vital signs while awaiting EMS 1, 2
4. Provide EMS with clinical information including history of chest pain with left arm tingling, palpitations, and dyspnea 1
5. Do not delay transport to obtain an office ECG or other testing 1