Immediate Management of Sudden Onset Chest Pain Radiating to the Back

Critical First Actions

The European Society of Cardiology recommends applying the Aortic Dissection Detection (ADD) score immediately upon patient contact, awarding one point for high-risk conditions, high-risk pain features, or high-risk examination features, with an ADD score ≥1 indicating high risk for aortic dissection (91% sensitivity) 1
The American College of Cardiology suggests instructing the patient to call 9-1-1 immediately and directing EMS to transport suspected aortic dissection patients to centers with interventional cardiology, cardiac surgery, and advanced imaging capabilities 2
The European Heart Society states that any ADD score ≥1 mandates immediate transport to a facility with advanced imaging and surgical capability 1

The European Heart Society recommends placing the patient on continuous cardiac monitoring with emergency resuscitation equipment immediately available, and obtaining and interpreting 12-lead ECG within 10 minutes of first medical contact 1
The American College of Cardiology suggests checking bilateral arm blood pressures and pulses in all extremities, with a systolic differential >20 mmHg or pulse deficit strongly suggesting dissection 1

The European Society of Cardiology recommends not administering aspirin, P2Y12 inhibitors, or anticoagulation if the ADD score ≥1 (suspected aortic dissection), and targeting heart rate <60 bpm and systolic blood pressure 100-120 mmHg using intravenous beta-blockers as first-line therapy 1
The European Heart Society suggests providing aggressive pain control with intravenous opioids if the ADD score ≥1 (suspected aortic dissection) 1

The American College of Cardiology recommends obtaining cardiac troponin as soon as possible after ED arrival, and arranging CT angiography of the chest with IV contrast as the definitive test for aortic dissection 4
The European Heart Society suggests considering focused cardiac ultrasound (FoCUS) in the pre-hospital or ED setting to support the diagnosis of aortic dissection, particularly when ECG shows ischemic changes 1

The American College of Cardiology states that elderly patients may present atypically with generalized weakness, stroke, syncope, or altered mental status rather than classic chest pain, and diabetic patients may have blunted pain perception due to autonomic dysfunction 4
The European Society of Cardiology recommends considering the substantially elevated risk for aortic dissection in patients with hypertension, known aortic valve disease, or connective tissue disorders 1