What is the significance of neck pain and palpitations in a patient with a history of cardiovascular disease or risk factors for cardiac disease, and how is it related to acute coronary syndrome?

Association of Neck Pain and Palpitations with Acute Coronary Syndrome

Neck pain is a recognized atypical presentation of acute coronary syndrome and should be taken seriously, particularly when combined with other concerning features, while palpitations alone are not a typical manifestation of ACS but may represent associated arrhythmias. 1

Neck Pain as an Anginal Equivalent

Neck pain represents a well-documented anginal equivalent that can occur with or without chest discomfort in patients experiencing acute coronary syndrome. The ACC/AHA guidelines explicitly state that patients with ACS "may have no chest discomfort but present solely with jaw, neck, ear, arm, shoulder, back, or epigastric discomfort" 1. This is particularly important because:

• Neck discomfort qualifies as an atypical presentation that does NOT exclude ACS, even when it occurs as the sole presenting symptom 1
• The combination of left arm pain with jaw/neck pain is specifically noted as concerning for potential cardiac ischemia, even with normal coronary imaging 2
• Women are especially prone to presenting with atypical symptoms including neck pain, which increases the risk of underdiagnosis 2

Clinical Significance and Risk Stratification

When evaluating neck pain in the context of possible ACS, the following factors increase the likelihood of acute ischemia:

• Age ≥65 years is the single most important risk factor, outweighing even the nature of the pain itself 1
• Prior history of coronary artery disease ranks as the second most important historical factor 1
• Presence of ≥3 traditional cardiovascular risk factors (hypertension, diabetes, hyperlipidemia, smoking, family history) 1, 3
• Pain occurring at rest or lasting >20 minutes suggests possible myocardial infarction rather than stable angina 4
• Associated diaphoresis has 95% specificity (LR 5.18) for ACS 4

Important Caveat About Atypical Features

The guidelines emphasize a critical point: although atypical characteristics do not increase the probability of ACS, they also do NOT exclude it 1. In the Multicenter Chest Pain Study, acute ischemia was diagnosed in patients with various "atypical" presentations, demonstrating that relying on symptom characteristics alone can lead to missed diagnoses 1.

Palpitations in the Context of ACS

Palpitations are not listed among the typical or atypical presentations of acute coronary syndrome in any of the major guidelines 1, 5, 6. However, they may represent:

• Arrhythmias secondary to myocardial ischemia or infarction, which occur as complications rather than presenting symptoms
• Anxiety or heightened sympathetic tone accompanying acute cardiac events
• An alternative diagnosis that should be considered alongside cardiac evaluation

Recommended Diagnostic Approach

For patients presenting with neck pain and palpitations with cardiovascular risk factors:

1. Obtain 12-lead ECG within 10 minutes to identify ST-elevation MI, ST depression, T-wave inversions, or Q waves 1, 4, 5

2. Measure cardiac troponin immediately and serially according to institutional protocol 4, 5

3. Apply validated risk scores such as:

   • HEART score (0-10): High-risk range 7-10 has LR 13 for ACS 7
   • TIMI score (0-7): High-risk range 5-7 has LR 6.8 for ACS 1, 7
   • These scores incorporate age, risk factors, ECG findings, and troponin 1, 7

4. Consider stress testing with imaging or coronary CTA if initial workup is non-diagnostic but clinical suspicion remains, particularly in women where microvascular disease is more common 2

Common Pitfalls to Avoid

• Do not dismiss neck pain as "atypical" and therefore unlikely to be cardiac - this is explicitly warned against in guidelines 1
• Do not rely solely on the character of pain - age and risk factors may be more predictive than symptom quality 1
• Do not assume palpitations indicate ACS - they are not a recognized manifestation and may distract from the more concerning neck pain 1, 5
• Do not discharge patients with concerning features based on a single negative troponin - serial measurements are required 4, 5

Risk Remains Elevated Beyond Acute Phase

Even after initial evaluation, by 6 months, NSTE-ACS mortality rates may equal or exceed those of STEMI, and by 12 months, rates of death, MI, and recurrent instability exceed 10% 1. This underscores the importance of not missing the diagnosis during the initial presentation when neck pain is the primary symptom.