What is the management for a patient with chest pain on the right side and tachycardia?

Management of Right-Sided Chest Pain with Tachycardia

Immediately obtain a 12-lead ECG within 10 minutes of patient arrival and place the patient on continuous cardiac monitoring with emergency resuscitation equipment nearby, while simultaneously assessing for life-threatening causes including pulmonary embolism, acute coronary syndrome, aortic dissection, pneumothorax, and pericarditis. 1

Immediate Assessment and Stabilization

First 10 Minutes - Critical Actions

• Obtain and interpret a 12-lead ECG within 10 minutes to identify STEMI, NSTE-ACS patterns, or other life-threatening conditions 1
• Place patient on cardiac monitor immediately with defibrillator and emergency resuscitation equipment at bedside 1
• Measure cardiac troponin as soon as possible after presentation to detect myocardial injury 1
• Obtain vital signs focusing on heart rate, blood pressure in both arms (pulse differential suggests aortic dissection), respiratory rate, and oxygen saturation 1
• Obtain chest radiograph to evaluate for pneumothorax (unilateral absent breath sounds), pneumonia, pleural effusion, or widened mediastinum suggesting aortic dissection 1, 2

Physical Examination - Key Findings by Diagnosis

For Pulmonary Embolism (PE):

• Tachycardia plus dyspnea occurs in >90% of patients 1, 2
• Pain increases with inspiration (pleuritic) 1
• Right-sided chest pain is consistent with PE presentation 2

For Pneumothorax:

• Unilateral absence of breath sounds with hyperresonant percussion 1, 2
• Dyspnea and sharp pain worsening with inspiration 1

For Acute Coronary Syndrome:

• Diaphoresis, tachypnea, tachycardia may be present 1
• Right-sided chest pain can occur with ACS, particularly in diabetes, women, and elderly patients 1
• Examination may be completely normal in uncomplicated cases 1

For Aortic Dissection:

• Sudden onset "ripping" pain with radiation to back 1, 2
• Pulse differential between extremities (30% of patients) 1
• Severe pain with abrupt onset plus pulse differential plus widened mediastinum on chest X-ray gives >80% probability 1

For Pericarditis:

• Sharp, pleuritic pain that improves sitting forward and worsens supine 1, 2
• Pericardial friction rub may be audible 1
• Fever may be present 1

ECG-Directed Management Algorithm

If ST-Elevation Present:

• Treat according to STEMI guidelines immediately 1
• Decision for fibrinolytic therapy or primary PCI within 10 minutes of ECG interpretation 1
• Goal: door-to-balloon time ≤90 minutes or door-to-needle time ≤30 minutes 1

If ST-Depression or T-Wave Changes:

• Treat according to NSTE-ACS guidelines 1
• Administer aspirin, P2Y12 inhibitor (ticagrelor preferred), and anticoagulation (enoxaparin or UFH) 1
• Obtain serial troponins to detect rising or falling pattern 1

If Initial ECG Nondiagnostic:

• Perform serial ECGs, especially if clinical suspicion remains high, symptoms persist, or clinical condition deteriorates 1
• Consider supplemental leads V7-V9 to rule out posterior MI, as right coronary artery or left circumflex occlusions may be "electrically silent" on standard 12-lead 1
• Compare with previous ECGs if available 1
• Do not base decision-making solely on a single normal ECG, as up to 6% of patients with evolving ACS are discharged with normal ECG 1

Risk Stratification for Specific Diagnoses

High-Risk Features for Pulmonary Embolism:

• Tachycardia (>90% of PE patients) plus dyspnea 1, 2
• Pleuritic right-sided chest pain 2
• If high clinical suspicion, proceed directly to CTA with PE protocol 2

High-Risk Features for Aortic Dissection (ADD Score):

Score ≥1 indicates high risk and requires urgent imaging: 1

• High-risk conditions: Marfan syndrome, connective tissue disease, known aortic valve disease, family history of aortic dissection 1
• High-risk pain: abrupt/instantaneous onset, severe intensity, ripping/tearing quality 1
• High-risk exam: pulse deficit, systolic BP differential >20 mmHg, new aortic regurgitation murmur, focal neurologic deficit 1

Initial Treatment While Diagnostic Workup Proceeds

Pain Management:

• Administer morphine intravenously, titrated to pain severity 1
• Pain relief should begin even before ECG interpretation 1

For Suspected ACS:

• Aspirin (if not already given) 1
• Sublingual nitroglycerin for symptom relief (but response does not confirm or exclude ischemia) 1, 2
• Beta-blockers intravenously if tachycardia and hypertension present with suspected ischemia 1
• Oxygen only if hypoxemic 1

For Suspected Aortic Dissection:

• Target heart rate <60 bpm and systolic BP 100-120 mmHg 1
• Intravenous beta-blockers first (to prevent reflex tachycardia), followed by nitrates or calcium channel blockers if needed 1

For Suspected PE:

• Anticoagulation with enoxaparin or UFH if high clinical suspicion and no contraindications 1

Transfer and Disposition Decisions

Immediate Transfer to Catheterization Lab:

• STEMI on ECG 1
• NSTE-ACS with cardiogenic shock, life-threatening arrhythmias, or persistent ischemia despite initial management 1

Transfer to ED or Chest Pain Unit:

• Suspected NSTE-ACS without high-risk features for further troponin assessment and observation 1
• Undifferentiated chest pain requiring serial ECGs and troponin monitoring 1

Transfer to Intensive Care:

• Hemodynamic instability or signs of heart failure 1
• Confirmed or highly suspected aortic dissection 1
• Massive PE with hemodynamic compromise 1

Critical Pitfalls to Avoid

• Do not assume right-sided chest pain excludes ACS - symptoms on right side can occur with myocardial ischemia, particularly in diabetes, women, and elderly 1
• Do not rely on nitroglycerin response as diagnostic - relief with nitroglycerin does not confirm or exclude myocardial ischemia 1, 2
• Do not delay transfer from office setting for troponin testing - patients with suspected ACS should be transported urgently to ED by EMS 1, 2
• Do not assume normal initial ECG excludes ACS - up to 6% of evolving ACS patients have normal ECG, requiring serial ECGs 1
• Do not miss posterior MI - consider right-sided leads (V7-V9) as posterior wall ischemia is often "electrically silent" 1
• Do not overlook aortic dissection - check bilateral blood pressures and pulses in all patients with acute chest pain and tachycardia 1

Transport Considerations

• If patient presents to office setting with suspected ACS, transport urgently to ED by EMS - do not delay for additional testing 1
• Patients should not drive themselves or be driven by personal automobile - EMS transport reduces risk and allows for pre-hospital treatment 1
• High-risk patients should be directed to facilities with 24/7 interventional cardiology capability 1