What is the best approach to evaluate a 65-year-old female patient with left-sided chest pain, shortness of breath, and radiating pain to the right arm and shoulder?

Immediate Workup for 65-Year-Old Female with Left Chest Pain, Dyspnea, and Right Arm/Shoulder Pain

This patient requires immediate 12-lead ECG within 10 minutes and urgent evaluation for acute coronary syndrome (ACS), as women are at high risk for underdiagnosis and commonly present with atypical symptoms including pain radiating to the right side rather than the classic left arm radiation. 1, 2

Critical Initial Actions

Immediate ECG (Within 10 Minutes)

• Obtain 12-lead ECG immediately to identify ST-segment elevation myocardial infarction (STEMI), new ischemic changes, Q waves, or T-wave inversions 1, 2
• The 3-day duration does NOT exclude ACS—anginal symptoms can be intermittent and women frequently present with atypical patterns 1, 2
• If ECG shows STEMI or new ischemic changes, activate emergency medical services (EMS) for immediate transfer to emergency department for cardiac catheterization 2

Immediate Laboratory Testing

• Measure high-sensitivity cardiac troponin immediately to exclude myocardial injury 2, 3
• If initial troponin is normal but clinical suspicion remains, repeat at 1-3 hours using high-sensitivity assay 2
• The combination of troponin with clinical findings provides significantly more diagnostic information than history and physical examination alone 3

Focused History Elements

Women-specific considerations (as women present differently than men): 1, 2

• Assess for accompanying symptoms MORE common in women with ACS: dyspnea (present in your patient), diaphoresis, nausea, fatigue, or lightheadedness 1, 2
• Document if pain is exertional or at rest—both patterns can indicate ACS in women 2
• Note that pain radiating to the RIGHT arm/shoulder, while atypical, does NOT exclude cardiac ischemia in women and elderly patients 1

Critical symptom characterization: 1

• Duration and onset pattern: Anginal symptoms build gradually over minutes, not seconds 1
• Quality: Pressure, tightness, heaviness, squeezing, or burning (sharp pleuritic pain is less likely ischemic) 1
• Precipitating factors: Exertion, emotional stress, or occurrence at rest with minimal exertion suggests ACS 1
• Associated symptoms: Your patient has dyspnea, which commonly accompanies myocardial ischemia 1

Cardiovascular risk assessment: 1, 2

• Age 65 years is a significant risk factor 1
• Document diabetes, hypertension, hyperlipidemia, smoking, family history of premature coronary disease 2

Physical Examination

• Perform focused cardiovascular examination to identify complications: diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3 gallop, new murmur of mitral regurgitation 1
• Check for pulse differentials between extremities to exclude aortic dissection 1
• Palpate chest wall systematically—but remember that 7% of patients with reproducible chest wall tenderness still have ACS, so this does NOT exclude cardiac pathology 4

Risk Stratification

Apply HEART or TIMI Score

• Use HEART score (History, ECG, Age, Risk factors, Troponin) or TIMI score incorporating the first troponin result 3
• HEART score 7-10 (high risk): likelihood ratio 13 for ACS 3
• HEART score 0-3 (low risk): likelihood ratio 0.20 against ACS 3
• These validated scores outperform clinical gestalt alone 3

Differential Diagnosis Framework

Life-Threatening Causes to Exclude

Acute coronary syndrome: 1, 2

• Your patient's presentation (65-year-old woman, dyspnea, arm pain) fits the profile
• Women are at HIGH risk for underdiagnosis due to atypical presentations 1, 2

Pulmonary embolism: 1

• Consider given dyspnea and chest pain
• Tachycardia present in >90% of PE patients 1
• Obtain chest radiograph to evaluate pulmonary pathology 2

Aortic dissection: 1

• Less likely without sudden-onset "ripping" pain or pulse differentials
• But must be excluded in any patient with chest pain and dyspnea 1

Disposition Decision

If High-Risk Features Present:

Immediate EMS transfer to emergency department if: 1

• ECG shows STEMI, new ischemic changes, or ST-segment depression 1
• Elevated troponin 2
• Hemodynamic instability 1
• Ongoing chest pain at rest 1

If Initial Testing Normal:

• Serial troponin at 1-3 hours if high-sensitivity assay available 2
• Consider stress testing, coronary CT angiography, or cardiac MRI for intermediate-risk patients 2, 5
• Do NOT discharge without objective testing—history and physical examination alone cannot exclude ACS 3, 6

Critical Pitfalls to Avoid

• Do not dismiss atypical presentations in women—right arm radiation and dyspnea without classic left arm pain is still consistent with ACS 1, 2
• Do not rely on nitroglycerin response—relief with nitroglycerin is NOT diagnostic of myocardial ischemia 1
• Do not assume 3-day duration excludes ACS—unstable angina can be intermittent over days 1
• Do not use chest wall tenderness alone to exclude cardiac disease—7% with reproducible tenderness still have ACS 4
• Do not discharge without objective testing—clinical examination alone has insufficient predictive power 3, 6