Management of Chest Pain Radiating to the Back

Initial Assessment

The American College of Cardiology and Circulation recommend that sudden onset of ripping chest pain with radiation to the back is highly suspicious for acute aortic syndrome and requires immediate emergency department evaluation, with a focused cardiovascular examination to identify potentially serious causes including aortic dissection, pulmonary embolism, or acute coronary syndrome 1, 3
The American Heart Association, as published in Circulation, suggests that vital signs and physical examination findings such as pulse differentials between extremities (present in 30% of aortic dissections) are critical diagnostic clues 2
The description of pain as "worst chest pain of my life," especially in patients with hypertension or known aortic valve disease, significantly increases the likelihood of aortic dissection, according to the American College of Cardiology 3, 2

The American College of Cardiology recommends that patients with chest pain radiating to the back should be transported urgently to the emergency department, ideally by emergency medical services, and an ECG should be obtained and reviewed within 10 minutes of arrival to evaluate for STEMI or other acute cardiac conditions 1, 4
Cardiac troponin should be measured as soon as possible after presentation to the emergency department, as recommended by the American Heart Association, as published in Circulation 1

The American College of Cardiology recommends that computed tomography (CT) of the chest with intravenous contrast is the preferred initial imaging modality to evaluate for aortic dissection and pulmonary embolism 4
The American Heart Association, as published in Circulation, suggests that transthoracic echocardiography (TTE) is useful in patients with suspected valvular heart disease that may be contributing to the presentation, and if TTE is inadequate, transesophageal echocardiography (TEE) may be necessary, particularly when evaluating for aortic pathology 5

The American College of Cardiology and the American Heart Association, as published in Circulation, characterize acute aortic syndrome as sudden, severe "ripping" pain radiating to the back, often described as the "worst pain ever" 2
Acute coronary syndrome may present with pain radiating to the back, particularly with inferior wall myocardial infarction, according to the American College of Cardiology 6, 4
Pulmonary embolism typically presents with pleuritic chest pain, dyspnea, and tachycardia, as suggested by the American Heart Association, as published in Circulation 2

The presence of hypertension, known aortic valve disease, or connective tissue disorders increases the risk of aortic dissection, according to the American Heart Association, as published in Circulation 2

The American College of Cardiology suggests that elderly patients may have atypical presentations including generalized weakness, stroke, syncope, or altered mental status 6
Diabetic patients may have atypical presentations due to autonomic dysfunction, as noted by the American College of Cardiology 6