What is the appropriate management for chest pain radiating to the back?

Management of Chest Pain Radiating to the Back

Chest pain radiating to the back requires immediate evaluation for life-threatening conditions, particularly acute aortic syndrome, as this presentation strongly suggests aortic dissection which demands urgent intervention. 1

Initial Assessment

• Sudden onset of ripping chest pain with radiation to the back is highly suspicious for acute aortic syndrome and requires immediate emergency department evaluation 1
• A focused cardiovascular examination should be performed to identify potentially serious causes including aortic dissection, pulmonary embolism, or acute coronary syndrome 1
• Vital signs and physical examination findings such as pulse differentials between extremities (present in 30% of aortic dissections) are critical diagnostic clues 1
• 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 1

Immediate Actions

• Patients with chest pain radiating to the back should be transported urgently to the emergency department, ideally by emergency medical services 1
• An ECG should be obtained and reviewed within 10 minutes of arrival to evaluate for STEMI or other acute cardiac conditions 1
• Cardiac troponin should be measured as soon as possible after presentation to the emergency department 1
• Delayed transfer to the emergency department for cardiac troponin or other diagnostic testing should be avoided as it may increase morbidity and mortality 1

Diagnostic Approach

• Computed tomography (CT) of the chest with intravenous contrast is the preferred initial imaging modality to evaluate for aortic dissection and pulmonary embolism 1
• Transthoracic echocardiography (TTE) is useful in patients with suspected valvular heart disease that may be contributing to the presentation 1
• If TTE is inadequate, transesophageal echocardiography (TEE) may be necessary, particularly when evaluating for aortic pathology 1
• In patients with low risk for aortic dissection but concern for coronary disease, coronary CT angiography may be appropriate 2

Differential Diagnosis

High Priority Conditions (Require Immediate Action)

• Acute Aortic Syndrome: Characterized by sudden, severe "ripping" pain radiating to the back, often described as the "worst pain ever" 1, 3
• Acute Coronary Syndrome: May present with pain radiating to the back, particularly with inferior wall myocardial infarction 1
• Pulmonary Embolism: Typically presents with pleuritic chest pain, dyspnea, and tachycardia 1

Other Important Considerations

• Esophageal Rupture: Associated with emesis, subcutaneous emphysema, and unilateral decreased breath sounds 1
• Pericarditis: Often presents with sharp, pleuritic pain that may improve with sitting forward 1
• Musculoskeletal Pain: Usually positional and localized 1
• Gastroesophageal Disorders: May mimic cardiac pain but typically related to meals 1

Risk Stratification

• The presence of hypertension, known aortic valve disease, or connective tissue disorders increases the risk of aortic dissection 1
• Patients with prior abnormal stress tests, peripheral arterial disease, or pain radiating to both arms have higher likelihood of acute coronary syndrome 4
• ST-segment depression or other ECG evidence of ischemia significantly increases the probability of acute coronary syndrome 4

Common Pitfalls to Avoid

• Failing to recognize atypical presentations in women, elderly patients, and those with diabetes 5
• Relying solely on pain severity to determine urgency, as severity is a poor predictor of complications 5
• Delaying treatment while waiting for definitive diagnosis 5
• Misdiagnosing aortic dissection as acute coronary syndrome and administering anticoagulants, which could worsen outcomes in dissection 3
• Assuming chest pain with back radiation is musculoskeletal without appropriate evaluation 6

Special Considerations

• Women may present with different symptoms than men, including more frequent radiation of pain to the back, neck, and jaw 5
• Elderly patients may have atypical presentations including generalized weakness, stroke, syncope, or altered mental status 1
• Diabetic patients may have atypical presentations due to autonomic dysfunction 1

Remember that chest pain radiating to the back represents a high-risk feature that warrants immediate comprehensive evaluation, with particular attention to ruling out life-threatening conditions like aortic dissection.