What is the appropriate initial evaluation and management for a patient with severe, pressure-like bilateral shoulder pain associated with nausea, but without changes with position or breathing, and normal vital signs?

Immediate Cardiac Evaluation Required for Suspected Acute Coronary Syndrome

This patient requires immediate 12-lead ECG within 10 minutes, continuous cardiac monitoring with defibrillation capability, and cardiac biomarker assessment to exclude acute coronary syndrome (ACS), as bilateral shoulder pain with pressure-like quality, nausea, and diaphoresis represents a classic atypical presentation of myocardial ischemia, particularly concerning in women and older adults. 1, 2, 3

Critical Recognition of Atypical ACS Presentation

• Bilateral shoulder pain with nausea represents a high-risk presentation for ACS that requires immediate cardiac evaluation, as pain radiating to shoulders, back, or both arms is explicitly listed as a chief complaint requiring immediate triage assessment and ACS protocol initiation. 1

• The pressure-like quality of pain, association with nausea, and lack of positional or respiratory variation strongly suggest cardiac rather than musculoskeletal origin, as these features align with central/substernal compression, pressure, or tightness typical of myocardial ischemia. 1, 3

• Normal vital signs do not exclude ACS—patients with unstable angina or NSTEMI frequently maintain normal blood pressure and pulse, particularly early in presentation. 1

Immediate Diagnostic Protocol

Place patient in environment with continuous ECG monitoring and defibrillation capability immediately, as this is mandatory for all patients with possible ACS before any other evaluation. 1

Within 10 Minutes:

• Obtain stat 12-lead ECG to identify ST-segment elevation MI, ST-segment depression, T-wave inversion, or other acute ischemic patterns. 1, 2
• Establish IV access for potential urgent interventions. 2
• Draw initial cardiac troponin with planned repeat at 6 hours if initial is negative. 2

Brief Targeted History (Must Not Delay ACS Protocol):

• Prior history of coronary artery disease, prior MI, prior PCI or CABG, or angina on effort. 1
• Cardiovascular risk factors: smoking, hyperlipidemia, hypertension, diabetes mellitus, family history of premature CAD. 1, 3
• Current medications, particularly nitroglycerin use. 1
• Recent cocaine or methamphetamine use. 1

High-Risk Features in This Presentation

• Women present more frequently with atypical chest pain and symptoms, including shoulder pain, nausea, and diaphoresis rather than classic substernal chest pain, making this presentation particularly concerning. 1, 3, 4

• Nausea and vomiting associated with chest or shoulder discomfort is explicitly listed as requiring immediate ACS protocol initiation. 1, 3

• Pain radiating to shoulders, back, or both arms is a cardinal feature of ACS, with 61.9% of women versus 54.8% of men with MI reporting pain in jaw, neck, arms, or between shoulder blades. 3, 4

Management Algorithm Based on Initial ECG Results

If ECG Shows STEMI or High-Risk Features:

• Activate cardiac catheterization lab immediately for primary PCI or administer thrombolytics if PCI unavailable within 120 minutes. 1
• Administer aspirin 162-325 mg chewed immediately unless contraindicated. 1
• Administer P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) unless contraindicated. 1

If ECG Shows ST-Depression, T-Wave Inversion, or Positive Troponin:

• Continue cardiac monitoring and serial troponins at 6-hour intervals. 1, 2
• Immediate cardiology consultation for risk stratification. 1
• Initiate antiplatelet therapy (aspirin plus P2Y12 inhibitor) and anticoagulation (heparin or enoxaparin). 1

If Initial ECG Normal and Troponin Negative:

• Do not discharge—maintain continuous monitoring and repeat troponin at 6 hours, as 4-5% of MIs are missed on initial evaluation. 5
• Consider early provocative testing (stress test or pharmacologic stress imaging) or emergency cardiac imaging (echocardiography or nuclear perfusion) to identify occult acute coronary syndrome. 5

Critical Pitfalls to Avoid

• Never dismiss bilateral shoulder pain as musculoskeletal without excluding cardiac causes first, especially given the pressure-like quality and associated nausea. 1, 3

• Traditional risk assessment tools consistently underestimate cardiac risk in women and misclassify their symptoms as nonischemic, leading to delayed or missed diagnosis. 3, 4

• Normal vital signs provide false reassurance—patients with UA/NSTEMI frequently have normal blood pressure, normal heart rate, and normal jugular venous pressure. 1

• Lack of chest pain does not exclude ACS—some patients present solely with shoulder, neck, jaw, arm, back, or epigastric discomfort without any chest symptoms. 3, 4

Special Considerations for This Patient

• If patient has diabetes, maintain heightened suspicion as diabetic patients may have atypical presentations due to autonomic dysfunction. 1, 3

• If patient is elderly (>70 years), atypical symptoms such as generalized weakness, syncope, or change in mental status may be the only manifestations of ACS. 1

• Women derive equal benefit from aspirin, clopidogrel, anticoagulants, beta blockers, ACE inhibitors, and statins as men, but are at increased risk of bleeding complications requiring careful attention to weight-based and renal-adjusted dosing. 4

Laboratory Workup

• Complete blood count to assess for anemia. 2
• Basic metabolic panel including renal function and electrolytes. 2
• Liver function tests if considering alternative diagnoses. 2
• Serum lactate if concerned about shock or intestinal ischemia. 2

Only After Cardiac Evaluation is Complete

If ECG remains normal, serial troponins are negative at 6 hours, and provocative testing or cardiac imaging excludes ACS, then consider alternative diagnoses such as cervical radiculopathy, rotator cuff pathology, or referred pain from gastrointestinal sources—but cardiac evaluation must be completed first, as the immediate mortality risk from missed ACS far exceeds the risk from delayed diagnosis of other conditions. 2