What are the appropriate diagnostic steps and treatment options for chest pain radiating to the back?

Chest Pain Radiating to the Back: Immediate Evaluation for Aortic Dissection

Sudden onset of ripping chest pain radiating to the upper or lower back is highly suspicious for acute aortic syndrome (aortic dissection) and requires immediate CT angiography of the chest, abdomen, and pelvis for diagnosis and treatment planning. 1

Critical Red Flags Requiring Immediate Action

When chest pain radiates to the back, you must immediately assess for aortic dissection characteristics:

• Sudden onset "ripping" or "tearing" quality described as "worst chest pain of my life" 1
• Radiation to upper or lower back (this pattern is unlikely to be anginal) 1
• Pulse differential between extremities (present in 30% of cases, more common in Type A than Type B) 1
• Hypertension at presentation or known history 1
• Risk factors: bicuspid aortic valve, aortic dilation, connective tissue disorders (Marfan syndrome), or advanced age 1

The combination of severe pain + abrupt onset + pulse differential + widened mediastinum on chest X-ray yields >80% probability of dissection. 1

Immediate Diagnostic Algorithm

Within 10 Minutes of Arrival:

1. Obtain ECG to evaluate for STEMI (required within 10 minutes for all acute chest pain patients) 1
2. Perform focused cardiovascular examination checking specifically for:
   • Pulse differentials between all four extremities 1, 2
   • Blood pressure differentials 1
   • Aortic regurgitation murmur (present in 40-75% of Type A dissections) 1
   • Signs of cardiac tamponade 1

Immediate Imaging Based on Clinical Suspicion:

If aortic dissection is suspected based on the above features:

• CT angiography of chest, abdomen, and pelvis is the recommended first-line test for diagnosis and treatment planning 1
• If CT is contraindicated or unavailable, perform transesophageal echocardiography (TEE) or cardiac MRI 1

Do not delay imaging if clinical suspicion is high—this is a time-critical emergency. 1

Alternative Life-Threatening Causes to Consider

While aortic dissection is the primary concern with back radiation, also evaluate for:

Pulmonary Embolism:

• Presents with dyspnea, pleuritic chest pain, tachycardia (>90% of cases) 1, 2
• CTA with PE protocol is recommended for stable patients with high clinical suspicion 1, 2

Acute Coronary Syndrome:

• Gradual onset over minutes (not sudden) with retrosternal pressure/tightness 1
• Measure cardiac troponin as soon as possible after presentation 1
• Note: Sudden ripping pain radiating to back is unlikely to be anginal 1

Esophageal Rupture:

• History of emesis, subcutaneous emphysema, pneumothorax (20% of patients) 1
• Unilateral decreased or absent breath sounds 1

Critical Management Pitfalls to Avoid

Do not assume relief with nitroglycerin indicates cardiac ischemia—this is not a reliable diagnostic criterion and should not guide your differential. 1

Do not delay transfer from office settings—patients with suspected life-threatening causes of acute chest pain should be transported urgently to the ED by EMS, not sent for outpatient testing. 1

Do not miss the pulse differential—actively check all four extremities, as this finding is present in only 30% of cases but significantly increases probability of dissection when present. 1

Do not rely solely on chest X-ray—while widened mediastinum supports the diagnosis, its absence does not exclude dissection; proceed to CT angiography if clinical suspicion remains high. 1

Setting-Specific Protocols

Office/Outpatient Setting:

• Transport urgently to ED by EMS if aortic dissection or other life-threatening cause is suspected 1
• Do not delay for troponin or other diagnostic testing in the office 1

Emergency Department:

• ECG within 10 minutes 1
• Cardiac troponin measurement as soon as possible 1
• CT angiography immediately if aortic dissection suspected 1
• Focused cardiovascular examination to identify complications and guide diagnosis 1