What is the best course of action for a patient with a history of asthma, anxiety, and anemia, presenting with heart palpitations, chest pain, and left arm tingling, despite a normal cardiology workup and well-controlled asthma and anxiety?

Immediate Emergency Department Referral and Cardiac Evaluation

You made the correct decision by sending this patient to the emergency department immediately after checking the EKG. This patient presents with multiple high-risk features for acute coronary syndrome (ACS) that mandate urgent ED evaluation regardless of her prior normal cardiology workup, including chest pain with exertion that has since resolved, nocturnal chest pain with dyspnea, left arm tingling, and palpitations 1, 2.

Why This Patient Required Immediate ED Transfer

High-Risk Clinical Features Present

• Chest pain with radiation to left arm and associated tingling represents a classic presentation pattern for unstable angina or non-ST-elevation myocardial infarction (NSTEMI), particularly in women who often present with atypical symptoms 2, 3
• Nocturnal chest pain with inability to catch breath indicates rest angina, which is a Class I indication for immediate ED referral 1
• Chest pain precipitated by exertion (cleaning house) followed by resolution suggests unstable angina with a crescendo pattern 2
• Multiple episodes over short time period (during cleaning and overnight) represent accelerating symptoms requiring urgent evaluation 1

Critical Pitfall: Prior Normal Workup Does Not Exclude Current ACS

The fact that she had a normal cardiology workup in the past is irrelevant to current risk stratification 1. Coronary artery disease is progressive, and new plaque rupture or thrombosis can occur at any time regardless of prior testing results 2. Women are particularly at risk for underdiagnosis of ACS, and accompanying symptoms like dyspnea should be emphasized 2.

Required Emergency Department Evaluation

Immediate Actions (Within 10 Minutes of ED Arrival)

• 12-lead ECG must be obtained and interpreted within 10 minutes of ED arrival to identify ST-segment elevation, ST-segment depression, or T-wave changes indicating myocardial ischemia 1, 2, 3
• Cardiac troponin measurement as soon as possible to detect myocardial injury, with sensitivity >90% and specificity >95% 2, 3
• Continuous cardiac monitoring with defibrillator readily available 3
• Serial ECGs if initial ECG is nondiagnostic but clinical suspicion remains high 3

Risk Stratification Tools

The ED team should use TIMI or GRACE score to guide intensity of therapy, with higher scores indicating higher risk of adverse outcomes 2. This patient likely has an elevated risk score given multiple episodes, exertional component, and radiation pattern.

Management Considerations

Antiplatelet Therapy

• Aspirin 162-325 mg (chewed, not swallowed) immediately unless contraindicated, which reduces mortality when given early in ACS 2
• Dual antiplatelet therapy with aspirin plus P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) for confirmed ACS 2

Additional Medical Therapy

• Anticoagulation with unfractionated heparin, enoxaparin, or fondaparinux for confirmed ACS 2
• Beta-blockers, ACE inhibitors, and statins as indicated to reduce mortality and morbidity 2

Revascularization Decision

Coronary angiography and potential revascularization (percutaneous coronary intervention or coronary artery bypass grafting) will be determined based on coronary anatomy, troponin results, ECG findings, and risk stratification 2.

Special Considerations for This Patient

Anemia Impact

Her documented anemia may lower the threshold for myocardial ischemia by reducing oxygen-carrying capacity, making her more susceptible to demand ischemia even with less severe coronary stenosis. This should be communicated to the ED team.

Anxiety vs. Cardiac Symptoms

While she reports well-controlled anxiety, anxiety diagnosis should never be used to dismiss cardiac symptoms in a patient with this presentation pattern 2, 3. The temporal relationship to exertion and the radiation pattern strongly suggest a cardiac etiology.

Aspirin Discontinuation

The fact that she stopped taking aspirin is concerning and should be communicated to the ED team, as aspirin discontinuation in patients with underlying coronary disease increases thrombotic risk 2.

Critical Pitfalls to Avoid

• Do not rely on nitroglycerin response as diagnostic - esophageal spasm and other conditions may also respond 2, 3
• Do not delay transfer for office-based troponin testing - time-dependent treatment for ACS requires immediate ED evaluation 2, 3
• Do not assume young age or prior normal testing excludes ACS - coronary disease is progressive and can occur at any age 2
• Sharp or pleuritic pain does not exclude ACS - pericarditis and atypical presentations can occur 2

Transport and Monitoring

Transport by EMS rather than private vehicle is strongly preferred because emergency medical technicians can provide life-saving interventions (early CPR and defibrillation) if cardiac arrest develops en route, which occurs in approximately 1 in 300 patients with chest pain 1.