Acute Coronary Syndrome with Chief Complaint of Arm Pain: An Atypical Case Presentation

Introduction: Typically, Acute Coronary Syndrome (ACS) present with "pressure like, squeezing" substernal chest pain, with possible radiation to left jaw, arm, neck, and upper back. Additionally, autonomic symptoms, like diaphoresis, nausea and vomiting are also common. In the following ACS case, symptoms include localized left arm pain, mild muscle ache on the left chest, and mild dizziness without the typical symptoms of pressure-like chest pain, nausea, vomiting, or diaphoresis. Presentation: A 49-year-old male with history of 4 pack-years of tobacco smoke use presented to urgent care with left arm pain. He thought the pain to be related to history of left arm fracture as a child. This episode of left arm pain lasted 4 hours and did not improve with acetaminophen. He also reported a "muscle ache" over the left chest, and slight lightheadedness. He denied sub-sternal pressure, shortness of breath, nausea, vomiting, or diaphoresis. Initial EKG at urgent care showed lateral T-wave changes and point of care (POC) troponin test was 0.13 ng/ml. POC Troponin-I at hospital ED was 0.76 ng/ml. Cardiac catheterization revealed occlusion of 3 coronary arteries and 3 drug-eluting stents were subsequently placed. Conclusion: Patients with atypical presentation of ACS that are not initially diagnosed with ACS have greater morbidity and mortality. Keep atypical symptoms of ACS in mind when evaluating patients. High sensitivity POC Troponin I could reduce diagnostic time with potential for major benefits for patients and emergency departments.