What causes pain in the right upper chest radiating to the upper right back?

Right Upper Chest Pain Radiating to Upper Right Back: Differential Diagnosis

The most critical immediate concern is acute aortic syndrome (aortic dissection), which characteristically presents with sudden-onset "ripping" or "tearing" pain radiating to the back and requires emergent evaluation. 1

Life-Threatening Causes Requiring Immediate Evaluation

Acute Aortic Syndrome (Highest Priority)

• 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. 1
• This presentation is particularly concerning in hypertensive patients or those with known bicuspid aortic valve or aortic dilation 1
• Patients often describe this as the "worst chest pain of my life" 1
• Check for pulse differentials between extremities and blood pressure differences between arms immediately 2, 3

Acute Coronary Syndrome

• While angina typically presents as retrosternal discomfort with left-sided radiation, right-sided chest pain can occur in patients with diabetes, women, and elderly patients 1
• Sharp or stabbing pain does not exclude ACS, particularly in high-risk populations 2, 3
• Obtain an ECG within 10 minutes of presentation and measure cardiac troponin immediately 2, 3
• Associated symptoms suggesting cardiac origin include dyspnea, diaphoresis, nausea, lightheadedness, or syncope 1

Pulmonary Embolism

• Classic triad includes dyspnea, tachycardia, and pleuritic chest pain 2
• Sharp pain worsening with inspiration is characteristic 1, 2
• Assess for risk factors including recent immobilization, surgery, malignancy, or prior DVT 2

Pneumothorax

• Presents with sharp, pleuritic chest pain of sudden onset 2
• Examine for decreased breath sounds unilaterally and dyspnea 2, 3

Non-Life-Threatening Cardiac Causes

Acute Pericarditis

• Sharp chest pain that increases with inspiration and lying supine, improves when sitting forward 1, 2
• Listen for pericardial friction rub on examination 2
• Pain is positional, which distinguishes it from ischemic causes 1

Musculoskeletal Causes

Costochondritis/Chest Wall Pain

• Tenderness to palpation of the chest wall is the hallmark finding indicating musculoskeletal origin 4
• Pain reproducible by palpation provides the highest diagnostic information against angina in patients without previous coronary artery disease 4
• Pain that varies with breathing, turning, twisting, or bending is reassuring 4
• Point tenderness makes cardiac ischemia less likely 1, 4
• However, never assume safety based on musculoskeletal findings alone without proper cardiac evaluation 4

Other Important Considerations

Pulmonary Causes

• Pleuritis/pleurisy: Sharp, localized chest pain worsening with deep breathing or coughing, may be associated with pneumonia or viral infection 2
• Pneumonia: Pleuritic chest pain with dyspnea, fever, and productive cough; check for egophony and dullness to percussion 2, 5

Gastrointestinal Causes

• Esophageal spasm can mimic cardiac pain and may respond to nitroglycerin 1, 2
• Gastroesophageal reflux disease presents with burning retrosternal pain, acid regurgitation 5, 6

Diagnostic Algorithm

Step 1: Immediate Assessment

• Obtain vital signs and assess hemodynamic stability 2, 3
• Obtain ECG within 10 minutes 2, 3
• Measure cardiac troponin immediately 2, 3

Step 2: Characterize Pain Systematically

• Nature: Ripping/tearing suggests dissection; sharp/pleuritic suggests pulmonary or pericardial; reproducible suggests musculoskeletal 1, 4
• Onset: Sudden onset with back radiation is highly suspicious for aortic dissection 1
• Duration: Fleeting pain (seconds) is unlikely ischemic; gradual buildup over minutes suggests angina 1
• Associated symptoms: Diaphoresis, nausea, dyspnea suggest cardiac origin 1

Step 3: Physical Examination

• Check for pulse differentials and blood pressure differences between arms 2, 3
• Auscultate for decreased breath sounds, friction rub 2, 3
• Palpate chest wall for reproducible tenderness 4

Step 4: Risk Stratification

• Assess cardiovascular risk factors including age, hypertension, diabetes, smoking, and family history 1, 2

Critical Red Flags Requiring Emergency Department Transfer

• Age >75 years with accompanying dyspnea, syncope, or acute delirium 3
• ECG abnormalities suggestive of ischemia 3
• Hemodynamic instability 3
• Associated diaphoresis, dyspnea, nausea, or syncope 3, 4
• Diabetes, renal insufficiency, or known cardiovascular disease 3

Common Pitfalls to Avoid

• Do not use nitroglycerin response as a diagnostic criterion for ischemia, as esophageal spasm can also respond 1
• Do not dismiss sharp pain as non-cardiac, especially in diabetics, women, and elderly patients 1, 2
• Do not assume musculoskeletal origin without ruling out life-threatening causes first, even with reproducible chest wall tenderness 4
• Do not overlook aortic dissection in the differential, as this is the most characteristic presentation for right upper chest pain radiating to the back 1