What is the best course of action for a 67-year-old patient with recent stent placement (percutaneous coronary intervention) and new onset left shoulder pain radiating to the neck, who has been taking over-the-counter (OTC) ibuprofen (nonsteroidal anti-inflammatory drug) for pain management?

Immediate Cardiac Evaluation Required

This 67-year-old patient with recent stent placement presenting with new-onset left shoulder pain radiating to the neck requires immediate cardiac evaluation to rule out acute coronary syndrome, and ibuprofen must be discontinued immediately due to significantly increased cardiovascular risk in post-PCI patients. 1, 2

Critical Safety Issue: NSAID Use Post-Stent Placement

Ibuprofen is contraindicated in this clinical scenario. The patient's use of 4 tablets of OTC ibuprofen (likely 800-1600mg total dose) poses serious cardiovascular risk:

• NSAIDs should not be administered to patients with recent coronary intervention, as they significantly increase mortality risk in post-MI and post-PCI patients 3
• Post-MI patients taking NSAIDs with COX-2 selectivity showed hazard ratios for death of 2.40-2.80, with the increased risk beginning in the first week of treatment 4
• The FDA black box warning specifically addresses NSAID use after coronary artery bypass graft surgery, and similar cardiovascular thrombotic risks apply to all recent coronary interventions 2
• Observational studies demonstrate that NSAID-treated patients in the post-MI period had a 20 per 100 person-years incidence of death compared to 12 per 100 person-years in non-NSAID exposed patients 2

Differential Diagnosis: Cardiac vs. Musculoskeletal

The clinical presentation raises significant concern for cardiac ischemia rather than simple musculoskeletal pain:

• Left shoulder pain radiating to the neck in a patient with recent stent placement (within weeks) is a classic presentation of cardiac ischemia 1
• Pain severity of 10/10 that is unresponsive to muscle relaxants but partially responsive to high-dose NSAIDs does not exclude cardiac etiology 1
• Inability to lie on the left side could reflect cardiac positioning sensitivity rather than purely mechanical shoulder pathology 5
• The absence of recalled trauma in a patient who has been avoiding lifting activities makes primary musculoskeletal injury less likely 1

Immediate Management Algorithm

Step 1: Emergency Cardiac Assessment

• Obtain immediate 12-lead ECG to evaluate for ST-segment changes, T-wave inversions, or other ischemic patterns 1
• Measure high-sensitivity cardiac troponin immediately and serially (at presentation and 3-6 hours later) 1
• Monitor vital signs including blood pressure and oxygen saturation 1
• Assess for other ACS symptoms: dyspnea, diaphoresis, nausea, or radiation to jaw/arm 1

Step 2: Discontinue NSAID Immediately

• Stop all ibuprofen use immediately given recent PCI 4, 2
• Document the total dose taken and timing of last dose 2

Step 3: Alternative Pain Management

• If cardiac ischemia is ruled out: Use acetaminophen up to 4g daily as first-line analgesic 4
• If pain persists after acetaminophen: Consider tramadol or small doses of opioids (morphine 2-4mg IV every 5-15 minutes or fentanyl 25-50μg IV) rather than NSAIDs 1, 4
• Avoid all NSAIDs including naproxen, despite its relatively lower cardiovascular risk, given the very recent stent placement 4, 3

Step 4: If Cardiac Ischemia is Confirmed

• Administer sublingual nitroglycerin 0.3-0.4mg every 5 minutes up to 3 doses (if systolic BP ≥90 mmHg) 1
• Give aspirin 162-325mg orally (chewed for faster absorption) if not already on maintenance dose 1
• Ensure dual antiplatelet therapy compliance: aspirin 75-100mg daily plus clopidogrel 75mg daily should be continued for the full prescribed duration (typically 6-12 months post-stent) 1
• Arrange urgent cardiology consultation and possible coronary angiography 1

Step 5: If Cardiac Workup is Negative

• Only after cardiac causes are definitively excluded, consider musculoskeletal evaluation with shoulder radiographs (AP views in internal/external rotation plus axillary or scapula-Y view) 1
• Refer to physical therapy for conservative management if rotator cuff pathology or other mechanical shoulder disorder is identified 1, 6

Critical Monitoring Requirements

For the next 48-72 hours, this patient requires:

• Serial cardiac biomarkers if initial troponin is elevated or borderline 1
• Continuous cardiac monitoring if any ECG abnormalities are present 1
• Blood pressure monitoring, as NSAIDs can worsen hypertension and heart failure 2
• Assessment for signs of stent thrombosis: recurrent chest pain, ST-segment elevation, or hemodynamic instability 1

Common Pitfalls to Avoid

• Do not assume musculoskeletal etiology simply because the patient describes "shoulder pain" - cardiac ischemia commonly presents as shoulder and neck pain without classic chest pain, especially in older adults 5, 6
• Do not continue NSAIDs even if cardiac workup is initially negative, given the patient's recent stent placement and ongoing cardiovascular risk 4, 2
• Do not delay cardiac evaluation to pursue imaging of the shoulder first - the temporal relationship to recent PCI mandates cardiac evaluation as the priority 1
• Do not substitute one NSAID for another (such as switching from ibuprofen to naproxen) in this high-risk post-PCI patient - all NSAIDs carry increased cardiovascular risk 4, 3, 2

Long-Term Pain Management Strategy

If musculoskeletal shoulder pain is ultimately confirmed after cardiac exclusion:

• Implement a stepped-care approach: acetaminophen → tramadol → physical therapy → consideration of subacromial corticosteroid injection if conservative measures fail 4, 6
• NSAIDs should remain avoided for at least 12 months post-stent placement, and potentially indefinitely given established coronary artery disease 1, 4
• Ensure gastroprotection with proton pump inhibitor given dual antiplatelet therapy, which increases gastrointestinal bleeding risk 1