What is the cause of shoulder pain and vomiting in a patient undergoing an outpatient cardiac examination?

From the Guidelines

For a patient presenting with shoulder pain and vomiting during an outpatient cardiac exam, immediate evaluation for possible acute coronary syndrome (ACS) is recommended, particularly focusing on myocardial infarction which can present with atypical symptoms including referred pain to the left shoulder and autonomic symptoms like vomiting. The patient should receive aspirin 325mg chewed immediately unless contraindicated, as recommended by the guidelines 1.

Key Considerations:

• Vital signs, a 12-lead ECG, and cardiac biomarkers (troponin) should be obtained promptly to assess for ACS.
• While awaiting results, consider antiemetics such as ondansetron 4mg IV/PO for symptom relief.
• If ACS is confirmed, initiate dual antiplatelet therapy with aspirin 81mg daily plus ticagrelor 180mg loading dose followed by 90mg twice daily or clopidogrel 600mg loading dose followed by 75mg daily.
• Pain management with nitroglycerin 0.4mg sublingual every 5 minutes for up to 3 doses may help if systolic blood pressure remains above 90mmHg. These symptoms warrant urgent attention as they may represent cardiac ischemia, particularly since shoulder pain can be referred from cardiac origins via shared neural pathways, and vomiting can result from vagal stimulation during cardiac events, as noted in the guidelines 1.

Additional Recommendations:

• Patients with possible ACS and negative cardiac biomarkers who are unable to exercise or who have an abnormal resting ECG should undergo a pharmacological stress test, as recommended by the guidelines 1.
• Patients who develop recurrent symptoms during observation suggestive of ACS or in whom the follow-up studies (12-lead ECG, cardiac biomarkers) show new abnormalities should be admitted to the hospital, as stated in the guidelines 1.
• Continuity of care is important in the overall management of patients with a chest pain syndrome, and the patient's primary physician should be notified of the results of the evaluation and should receive a copy of the relevant test results, as emphasized in the guidelines 1.

From the Research

Outpatient Cardiac Exam and Shoulder Pain

• Shoulder pain can be a presenting symptom in patients with acute coronary syndrome (ACS), although it is not as common as chest discomfort 2, 3.
• In patients with suspected ACS, electrocardiography and troponin measurements are essential for diagnosis 2, 3.
• Shoulder pain can also be caused by various other conditions, such as rotator cuff or subacromial bursa problems, and a careful history and physical examination are necessary to determine the cause 4, 5.

Vomiting and Cardiac Conditions

• Vomiting is not a typical symptom of ACS, but it can occur in some cases, especially if the patient is experiencing severe pain or anxiety 2, 3.
• In patients with suspected ACS, vomiting can be a sign of a more severe condition, such as myocardial infarction, and requires immediate medical attention 2, 3.

Diagnostic Approach

• For patients presenting with possible ACS, electrocardiography should be performed immediately, and troponin measurements should be taken to evaluate for myocardial infarction 2, 3.
• In patients with shoulder pain, a careful history and physical examination are necessary to determine the cause, and imaging studies may be needed in some cases 4, 5.
• Prehospital administration of aspirin and nitroglycerin may be beneficial for patients with suspected ACS, although the certainty of evidence is very low 6.