Acute myocardial infarction - It's pain radiating to the right arm we have to worry about!

​It was only back in in 1987 when William Heberdeen (not to confound with William Heberdeen, a London doctor who described the Heberdeen nodes back in the 18th century) published the first description of ischemic chest pain. It was the birth of the classical image of strangling chest pain that occasionally radiates to the left arm, associated with exertion and relieved by rest.

A recent publication in the BMJ shows, that positive troponin levels are found frequently in patients with non-cardiac problems. This finding underlines the importance of good history taking, including the assessment of chest pain (CP) characteristics. 
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Circulation. 2018;138:e618–e651. (Click image for link to article)

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The TRAPID-AMI Study
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McCord J et al. have taken a closer look at chest pain and associated symptoms and their association with the diagnosis of acute myocardial infarction. They also analysed these symptoms in relation to the size of the AMI.

They performed an

international, multicenter diagnostic study

in which they evaluated 

1282 patients admitted for possible AMI to emergency departments in Europe, the US and Australia

The outcome was

the correlation of symptoms with the diagnosis of AMI and its relation to myocardial infarction size

They found that

1. only 4 symptoms were independently predictive of AMI

- Radiation to the right arm/ shoulder (OR 3.0, CI 1.8-5.0)
- Chest pressure (OR 2.5, CI 1.3-4.6)
- CP worsened by physical activity (OR 1.7, CI 1.2-2.5)
- Radiation to left arm/ shoulder (OR 1.7, CI 1.1-2.4)


2. Patients with more than 1 of the 4 symptoms were more likely to have AMI
- For patients who had all 4 symptoms, 55% had a diagnosis of AMI


3. Patients with larger AMI's were more likely to have 
- pulling CP
- pain in the right upper chest (right supramammillary area)
- and right arm/shoulder radiation

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​- It's time to get rid of the classical image of CP radiating only into the left arm. While this might still be the predominant complaint at presentation, it's the right sided shoulder/ arm pain we should keep a close eye on!

- Chest pain radiating to the right shoulder/ arm is more predicitive of myocardial infarction than left sided chest pain

- And remember: a positive Troponin alone does not fullfill the diagnostic criteria of AMI!



Crit Pathw Cardiol. 2019 Mar;18(1):10-15.
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