What is the most appropriate next step in management for a 22‑year‑old with occasional crushing chest pain radiating to the shoulders and back that lasts about an hour and then resolves?

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Immediate Management of a 22-Year-Old with Crushing Chest Pain Radiating to Shoulders and Back

Obtain a 12-Lead ECG Within 10 Minutes and Measure High-Sensitivity Cardiac Troponin Immediately

This patient requires urgent evaluation to exclude acute coronary syndrome (ACS), aortic dissection, and pulmonary embolism—even at age 22—because crushing chest pain radiating to the shoulders and back lasting one hour represents a classic high-risk presentation that cannot be dismissed based on age alone. 1, 2

Why This Young Patient Requires Full Cardiac Evaluation

Age Does Not Exclude Life-Threatening Disease

  • Young women are at higher risk for under-diagnosis of ACS because clinicians incorrectly assume age provides protection; women frequently present with atypical symptoms including throat discomfort, nausea, and fatigue rather than classic substernal pressure. 1, 2

  • Approximately 13% of patients with pleuritic-type or sharp chest pain still have acute myocardial ischemia, and a normal physical examination does not exclude uncomplicated myocardial infarction. 1, 2

The Pain Pattern Is High-Risk

  • Crushing chest pain that builds gradually over minutes and radiates to the left arm, jaw, neck, or shoulders and back is the classic presentation of ACS. 1, 2

  • Sudden "ripping" or "tearing" chest pain radiating to the upper or lower back is highly suspicious for acute aortic dissection; although less common in young patients, connective-tissue disorders (e.g., Marfan syndrome, Ehlers-Danlos syndrome) and bicuspid aortic valve markedly increase risk even in the third decade of life. 1, 3, 4

  • Pain lasting approximately one hour that then resolves is consistent with unstable angina or transient myocardial ischemia; the average patient with prolonged rest angina (>20 minutes) delays seeking care for approximately 2 hours. 1

Immediate Diagnostic Algorithm (First 10 Minutes)

Step 1: Obtain 12-Lead ECG and Interpret for Acute Changes

  • Acquire and review the ECG within 10 minutes of arrival for ST-segment elevation, ST-segment depression, T-wave inversion, new left bundle-branch block, or other acute ischemic changes. 1, 2

  • If the initial ECG is nondiagnostic but suspicion remains high, obtain serial ECGs every 15–30 minutes to capture evolving ischemic patterns. 2

  • Add posterior leads (V7–V9) when intermediate-to-high suspicion for ACS exists and the standard ECG is nondiagnostic, to detect posterior myocardial infarction. 2

  • A normal initial ECG does not exclude ACS; 30–40% of acute myocardial infarctions present with a normal or nondiagnostic ECG, and approximately 5% of ACS patients have a normal first ECG. 2, 5

Step 2: Measure High-Sensitivity Cardiac Troponin Immediately

  • Draw high-sensitivity cardiac troponin (hs-cTn) as soon as possible; it is the most sensitive and specific biomarker for myocardial injury. 1, 2

  • A single normal hs-cTn does not rule out ACS; repeat measurement at 3–6 hours is required to safely exclude myocardial injury. 1, 2

Step 3: Perform Focused Cardiovascular Examination

  • Check bilateral arm blood pressures and pulses in all extremities; a systolic blood-pressure difference >20 mmHg between arms or pulse differential strongly suggests aortic dissection (present in ~30% of cases, more common in type A). 1, 3, 4

  • Auscultate for a new aortic-regurgitation murmur (present in 40–75% of type A dissections), pericardial friction rub (pericarditis), or an S3 gallop (heart failure or myocarditis). 1, 2

  • Assess for tachycardia (>100 bpm occurs in >90% of pulmonary embolism patients), tachypnea (>20 breaths/min in ~70% of PE), and oxygen saturation. 1, 2

Risk Stratification Based on Initial Findings

If ECG Shows ST-Elevation or New Ischemic Changes

  • Activate emergency medical services immediately and transport to a facility with interventional cardiology and cardiac surgery capabilities. 1, 4

  • Initiate dual antiplatelet therapy (aspirin + P2Y12 inhibitor) and anticoagulation only if aortic dissection has been excluded; do not administer antiplatelet or anticoagulation therapy if the Aortic Dissection Detection (ADD) score ≥1. 4

If ECG Is Normal or Nondiagnostic

  • Proceed with serial troponin measurement at 3–6 hours. 1, 2

  • Calculate the Aortic Dissection Detection (ADD) score: award one point for high-risk conditions (e.g., Marfan syndrome, bicuspid aortic valve, family history of aortic disease), high-risk pain features (sudden onset, tearing/ripping quality, radiation to back), or high-risk examination features (pulse differential, blood-pressure differential, new aortic-regurgitation murmur). An ADD score ≥1 indicates 91% sensitivity for aortic dissection and mandates immediate CT angiography of the chest. 4

  • If both troponins are normal and ADD score is 0, the patient can be classified as low-risk for ACS and aortic dissection; however, outpatient stress testing or coronary CT angiography within 72 hours is still recommended because young women with atypical presentations remain at risk for missed diagnoses. 1, 2

Definitive Imaging When Aortic Dissection or Pulmonary Embolism Is Suspected

CT Angiography of the Chest with IV Contrast

  • CT angiography is the preferred initial imaging modality to evaluate for aortic dissection and pulmonary embolism simultaneously (the "triple rule-out" protocol). 3, 6

  • Arrange CT angiography immediately if the ADD score ≥1 or if clinical suspicion for aortic dissection or PE is intermediate-to-high. 3, 4

Focused Cardiac Ultrasound (FoCUS) or Transthoracic Echocardiography

  • Consider FoCUS in the emergency department to support the diagnosis of aortic dissection, particularly when the ECG shows ischemic changes that could represent either ACS or malperfusion from dissection. 4, 7

  • Transthoracic echocardiography is useful to evaluate for valvular heart disease, pericardial effusion, or regional wall-motion abnormalities; if inadequate, transesophageal echocardiography may be necessary. 3, 7

Common Pitfalls to Avoid

Do Not Dismiss ACS Based on Age or Gender

  • Young women are frequently under-diagnosed because clinicians assume age provides protection; women often present with nausea, dyspnea, fatigue, or throat discomfort rather than classic substernal pressure. 1, 2

Do Not Rely on Nitroglycerin Response

  • Relief with nitroglycerin is not diagnostic of myocardial ischemia; esophageal spasm and other conditions also respond to nitroglycerin. 1, 2

Do Not Assume a Normal Physical Exam Excludes ACS

  • Uncomplicated myocardial infarction can present with a completely normal examination; physical findings such as tachycardia, hypotension, crackles, or a new murmur increase suspicion but their absence does not rule out disease. 1, 2

Do Not Administer Antiplatelet or Anticoagulation Therapy Before Excluding Aortic Dissection

  • If the ADD score ≥1 (suspected aortic dissection), do not give aspirin, P2Y12 inhibitors, or anticoagulation; instead, target heart rate <60 bpm and systolic blood pressure 100–120 mmHg using intravenous beta-blockers as first-line therapy. 4

Do Not Delay Transfer for Troponin Testing in the Office Setting

  • For patients with acute chest pain and suspected ACS initially evaluated in the office, delayed transfer to the emergency department for troponin or other diagnostic testing should be avoided; transport urgently by EMS. 1, 4

Summary Algorithm

  1. Obtain 12-lead ECG within 10 minutes and measure high-sensitivity troponin immediately. 1, 2

  2. Check bilateral arm blood pressures and pulses in all extremities; calculate the ADD score. 3, 4

  3. If ECG shows ST-elevation or new ischemic changes, activate EMS and transport to a facility with interventional cardiology and cardiac surgery. 1, 4

  4. If ADD score ≥1, arrange immediate CT angiography of the chest; do not administer antiplatelet or anticoagulation therapy. 3, 4

  5. If ECG is normal and ADD score is 0, repeat troponin at 3–6 hours; if both troponins are normal, arrange outpatient stress testing or coronary CT angiography within 72 hours. 1, 2

  6. If both troponins are normal and pain is reproducible with palpation, consider costochondritis but still arrange outpatient cardiac testing given the high-risk pain pattern. 2

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Differential Diagnosis for Chest Pain

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Guideline

Management of Chest Pain Radiating to the Back

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

4
Guideline

Immediate Management of Sudden Onset Chest Pain Radiating to the Back

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

7
Research

The role of urgent transthoracic echocardiography in the evaluation of patients presenting with acute chest pain.

European journal of emergency medicine : official journal of the European Society for Emergency Medicine, 2012

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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