Evaluation of Intermittent Pulsating in Chest Near Right Sternal Border

Initial Assessment and Differential Diagnosis

The American College of Cardiology recommends that the immediate focus should be on excluding life-threatening causes through vital signs assessment, including blood pressure in both arms, heart rate, and respiratory rate, to evaluate for aortic dissection if pulse differential exists 1, 2
The American College of Cardiology suggests that cardiovascular examination should focus on auscultation at the right upper sternal border for aortic stenosis murmur or aortic regurgitation, assessment for accentuated P2 suggesting pulmonary hypertension, and evaluation of S2 splitting pattern 1
Aortic valve pathology, such as aortic stenosis, produces a harsh systolic murmur at the right upper sternal border, while severe stenosis results in a soft or absent A2 component of S2, according to the American College of Cardiology 1, 3
Right ventricular infarction, associated with inferior MI, causes the ST-segment vector to direct anteriorly and rightward, producing ST elevation in right-sided chest leads V3R and V4R, as stated in Circulation 4
Pulmonary hypertension produces an accentuated P2 and may cause visible right ventricular impulse, according to the American College of Cardiology 1
Costochondritis accounts for 42% of nontraumatic musculoskeletal chest wall pain and is diagnosed by tenderness to palpation of costochondral joints, as reported in the Journal of the American College of Cardiology and the Journal of the American College of Radiology 1, 5

The American College of Cardiology recommends characterizing the pulsation by timing, respiratory variation, and reproducibility, and performing a targeted examination, including auscultation for murmurs and assessment of S2 splitting pattern 1, 3
The European Heart Journal states that a completely normal ECG does not exclude acute coronary syndrome but significantly reduces probability, and that left ventricular hypertrophy or bundle branch blocks increase cardiac risk 2, 8
High-risk features requiring urgent evaluation include associated chest pain, dyspnea, or syncope, abnormal vital signs, new murmurs or abnormal heart sounds, and ECG abnormalities, according to the American College of Cardiology and Circulation 1, 4

Echocardiography is indicated when murmurs are detected on examination, S2 is single or paradoxically split, clinical suspicion for structural heart disease exists, or pulsations are associated with symptoms, as recommended by the American College of Cardiology and Circulation 1, 7, 9
The American College of Cardiology advises against dismissing pulsations in patients with cardiovascular risk factors, even if the examination seems benign, and recommends obtaining ECG and considering echocardiography 1, 2