Evaluation and Management of Chest Pain with Left Arm Radiation

Immediate Risk Stratification and Diagnostic Approach

The American Heart Association recommends obtaining a 12-lead ECG within 10 minutes to identify ST-elevation myocardial infarction (STEMI), ST depression, or other ischemic changes, with a strength of evidence level of I (high) 1, 2
The American College of Cardiology suggests measuring cardiac troponin immediately and repeating according to protocol, as elevated troponin with typical chest pain indicates NSTEMI, with a strength of evidence level of I (high) 2
A classic presentation of substernal chest pain radiating to the left arm has a high likelihood for ACS, with diaphoresis having 95% specificity (LR 5.18), according to the American Heart Association, with a strength of evidence level of IIa (moderate) 2
Pain lasting >20 minutes at rest suggests possible myocardial infarction, with a strength of evidence level of IIb (low-moderate), as recommended by the European Society of Cardiology 3, 4

The American College of Gastroenterology suggests that epigastric or substernal pain that can radiate to left arm may indicate Gastroesophageal Reflux Disease (GERD), with a strength of evidence level of IIa (moderate) 5
Bending forward increases intra-abdominal pressure and can precipitate GERD symptoms, according to the American Gastroenterological Association, with a strength of evidence level of IIb (low-moderate) 5
Pain reproducible with palpation and worsening with specific movements suggests musculoskeletal origin, with a strength of evidence level of III (low), as recommended by the American College of Rheumatology 5
The American Society of Echocardiography recommends transthoracic echocardiography if pericarditis is suspected, with a strength of evidence level of I (high) 2

The American College of Emergency Physicians recommends a focused cardiovascular examination for murmurs, rales, signs of heart failure, with a strength of evidence level of IIa (moderate) 3, 4
If troponin elevated or ECG shows ischemic changes, the American Heart Association recommends admitting for ACS management per cardiology protocols, with a strength of evidence level of I (high) 3, 2
If cardiac workup negative and pericarditis suspected, the American College of Cardiology suggests considering admission or close outpatient follow-up depending on hemodynamic stability, with a strength of evidence level of IIb (low-moderate) 2