Acute Aortic Syndrome and Other Causes of Right Upper Chest Pain

Life-Threatening Causes Requiring Immediate Evaluation

The American College of Cardiology recommends immediate evaluation for acute aortic syndrome, which characteristically presents with sudden-onset "ripping" or "tearing" pain radiating to the back 1, 2
Sudden onset of ripping chest pain with radiation to the upper or lower back is highly suspicious for aortic dissection and is unlikely to be anginal, especially in hypertensive patients or those with known bicuspid aortic valve or aortic dilation 1, 2
Patients with acute coronary syndrome may present with right-sided chest pain, particularly in patients with diabetes, women, and elderly patients, and sharp or stabbing pain does not exclude ACS 1, 2
The American College of Cardiology suggests obtaining an ECG within 10 minutes of presentation and measuring cardiac troponin immediately for patients with suspected acute coronary syndrome 3, 4

The American College of Cardiology notes that acute pericarditis presents with sharp chest pain that increases with inspiration and lying supine, improves when sitting forward, and is positional, which distinguishes it from ischemic causes 1, 2, 3

Tenderness to palpation of the chest wall is the hallmark finding indicating musculoskeletal origin, and pain reproducible by palpation provides the highest diagnostic information against angina in patients without previous coronary artery disease 6

The American College of Cardiology recommends obtaining vital signs and assessing hemodynamic stability, obtaining an ECG within 10 minutes, and measuring cardiac troponin immediately as part of the diagnostic algorithm 3, 4
Characterizing pain systematically, including nature, onset, duration, and associated symptoms, is crucial in diagnosing the cause of right upper chest pain 1, 2, 6

The American College of Cardiology identifies critical red flags requiring emergency department transfer, including age >75 years with accompanying dyspnea, syncope, or acute delirium, ECG abnormalities suggestive of ischemia, hemodynamic instability, and associated diaphoresis, dyspnea, nausea, or syncope 4, 6