What is the initial evaluation and management for a middle‑aged woman presenting to the emergency department with intermittent right‑sided chest discomfort that awakens her from sleep, associated right‑arm paresthesia, normal sinus rhythm on electrocardiogram, vomiting, chronic semaglutide (Ozempic)‑related gastrointestinal symptoms and bloody stools, and who is taking fluoxetine (Prozac)?

Initial Evaluation and Management of Right-Sided Chest Pain with Vomiting in a Woman on Semaglutide

This patient requires immediate emergency department evaluation with a 12-lead ECG within 10 minutes and cardiac troponin measurement to exclude acute coronary syndrome, despite the right-sided location and concurrent gastrointestinal symptoms. 1

Immediate Diagnostic Priorities

Life-Threatening Conditions to Exclude First

Acute coronary syndrome remains the primary concern despite right-sided chest pain, because women frequently present with atypical symptoms and are at high risk for underdiagnosis. 1, 2 The intermittent nature awakening her from sleep, associated arm paresthesia, and substernal radiation are concerning features that cannot be dismissed. 1

• Obtain serial 12-lead ECGs if the initial ECG is nondiagnostic but clinical suspicion remains high, as 30-40% of acute myocardial infarctions present with normal or nondiagnostic initial ECGs. 3

• Measure high-sensitivity cardiac troponin immediately and repeat at 1-3 hours (or 3-6 hours if conventional assay) to improve diagnostic accuracy. 3 A single normal troponin does not exclude ACS in this presentation. 1

• Consider posterior leads V7-V9 if the initial ECG is nondiagnostic, as posterior MI can present with right-sided symptoms. 3

Critical Gastrointestinal Differential

The chronic semaglutide use with bloody stools and acute vomiting raises concern for esophageal rupture or severe gastroparesis with complications. 4 However, this does not exclude concurrent cardiac pathology.

• Obtain upright chest radiography to evaluate for pneumomediastinum, subcutaneous emphysema, or pleural effusion that would suggest esophageal rupture (Boerhaave syndrome). 4, 3

• Assess for subcutaneous emphysema on physical examination by palpating the neck and chest wall. 3

Risk Stratification

High-Risk Features Present

This patient demonstrates multiple concerning elements:

• Prolonged intermittent rest pain awakening her from sleep (occurred twice over 3 hours). 1

• Associated arm paresthesia that women commonly report as an anginal equivalent rather than classic radiation. 1, 2

• Vomiting, which is more common in women with ACS (32% versus 23% in men). 2

• Substernal location on second episode, which is the classic distribution for myocardial ischemia. 1

Women-Specific Considerations

Women presenting with chest pain are at significant risk for underdiagnosis because traditional risk assessment tools underestimate their cardiac risk. 1, 2

• Accompanying symptoms in women with ACS include nausea (32%), vomiting, jaw/neck pain (10%), and epigastric discomfort (61.9%), all of which this patient demonstrates. 1, 2

• Do not dismiss cardiac causes based on right-sided location or concurrent GI symptoms, as women frequently present with atypical patterns. 1, 2

Immediate Management Algorithm

If ECG Shows STEMI or New Ischemic Changes

• Activate STEMI protocol immediately with goal of primary PCI door-to-balloon <90 minutes or fibrinolysis door-to-needle <30 minutes. 3

• Administer aspirin 162-325 mg (chewed) unless contraindicated by active GI bleeding. 3

• Withhold antiplatelet therapy temporarily if bloody stools suggest active upper GI bleeding until bleeding source is clarified. 1

If ECG is Nondiagnostic but Troponin Elevated

• Admit to coronary care unit with continuous cardiac monitoring. 3

• Initiate dual antiplatelet therapy and anticoagulation only after excluding active GI bleeding as the source of bloody stools. 3

• Plan urgent coronary angiography within 24-72 hours based on risk stratification. 3

If Both ECG and Initial Troponin Normal

• Observe in chest pain unit for 10-12 hours with serial troponins at 6-12 hours after symptom onset. 3

• Continue IV fluids and antiemetics for symptomatic management. 3

• Obtain gastroenterology consultation for evaluation of chronic GI symptoms with bloody stools, particularly in the context of prolonged semaglutide use. 3

Critical Pitfalls to Avoid

Do not attribute symptoms solely to semaglutide-related gastroparesis without excluding cardiac ischemia. 1 The temporal pattern of intermittent episodes awakening her from sleep is more consistent with unstable angina than medication side effects. 1

Do not use nitroglycerin response (or lack thereof) as a diagnostic criterion, as esophageal spasm and other GI conditions may also respond. 1, 4

Do not assume right-sided chest pain excludes ACS, especially in women who present with atypical distributions. 1, 2

Do not delay cardiac workup for GI evaluation when both systems may be involved. 3 Simultaneous evaluation is appropriate given the high-risk features.

Disposition Decision

This patient requires hospital admission regardless of initial troponin results due to:

• Multiple episodes of rest pain over 3 hours. 1
• Associated symptoms concerning for ACS in a woman. 1, 2
• Concurrent GI bleeding requiring evaluation. 3
• Need for serial cardiac biomarkers and observation. 1, 3

If low-risk criteria are eventually met (normal serial ECGs, negative troponins at 6-12 hours, resolution of symptoms), consider outpatient stress testing within 72 hours before discharge. 3, 5