What is the workup for a patient with intermittent right-sided chest pain of long duration?

Workup for Intermittent Right-Sided Chest Pain of Long Duration

For a patient with chronic, intermittent right-sided chest pain, obtain an immediate 12-lead ECG and perform a focused physical examination to exclude life-threatening cardiac causes, then systematically evaluate for musculoskeletal, pulmonary, and gastrointestinal etiologies based on pain characteristics and examination findings. 1, 2

Initial Assessment and Risk Stratification

History Taking - Critical Features

Pain Characteristics:

• Location and radiation: Right-sided chest pain that is localized to a very limited area or radiating below the umbilicus is unlikely to be myocardial ischemia 1
• Quality: Sharp, stabbing pain that increases with inspiration and lying supine is unlikely related to ischemic heart disease 1
• Duration: Fleeting chest pain lasting only seconds is unlikely to be related to ischemic heart disease, while anginal symptoms gradually build over minutes 1
• Precipitating factors: Positional chest pain or pain affected by palpation, breathing, turning, twisting, or bending suggests musculoskeletal etiology 2
• Associated symptoms: Absence of diaphoresis, dyspnea, nausea, or syncope significantly reduces likelihood of acute coronary syndrome 1, 2

High-Risk Features to Identify:

• Age >75 years, diabetes mellitus, renal insufficiency, or known coronary artery disease increases probability of cardiac etiology 1
• Women and elderly patients may present with atypical symptoms 1, 2

Physical Examination - Systematic Approach

Mandatory examination components:

• Chest wall palpation: Systematically palpate costochondral joints along the right chest wall to identify reproducible tenderness suggesting costochondritis or Tietze syndrome 1, 2
• Cardiovascular examination: Assess for heart murmurs (aortic stenosis, aortic regurgitation, hypertrophic cardiomyopathy), signs of heart failure (S3, crackles), and hemodynamic instability 1
• Pulmonary examination: Check for unilateral absence of breath sounds (pneumothorax), dullness to percussion, egophony (pneumonia), or pleuritic features 1
• Abdominal examination: Assess for right upper quadrant tenderness and Murphy sign (gallbladder disease) 1

Critical caveat: 7% of patients with reproducible chest wall tenderness may still have acute coronary syndrome, so chest wall tenderness alone does not definitively exclude cardiac pathology 3

Mandatory Initial Testing

Electrocardiogram

• Obtain 12-lead ECG immediately, even in outpatient setting with chronic symptoms, unless a clearly non-cardiac cause is evident 1, 2
• If ECG unavailable in office, refer to emergency department 2
• Serial ECGs should be performed if initial ECG is nondiagnostic and clinical suspicion remains 1
• ECG serves to exclude ST-segment elevation myocardial infarction (must be identified within 10 minutes), pericarditis, and signs of pulmonary embolism 1, 3

Cardiac Biomarkers

• Check high-sensitivity cardiac troponin if any concern for acute coronary syndrome exists, though less likely with chronic stabbing pain 2
• Troponin should be measured if patient has risk factors or any atypical features 2
• Do NOT delay transfer to emergency department for troponin testing in office setting if high-risk features are present 1, 2
• Troponin testing should rarely be requested in primary care for suspected acute coronary syndrome 4

Additional Laboratory Testing

• Hemoglobin to detect anemia as a precipitating factor 1
• Consider D-dimer if pulmonary embolism is in differential (though less likely with chronic intermittent symptoms) 5

Differential Diagnosis Framework

Life-Threatening Causes (Must Exclude First)

• Acute coronary syndrome: Retrosternal pressure building over minutes, radiation to left arm/jaw/neck, associated with diaphoresis or dyspnea 1, 2
• Pulmonary embolism: Acute dyspnea with pleuritic chest pain, tachycardia in >90% of patients 1, 2
• Aortic dissection: Sudden-onset "ripping" or "tearing" pain, pulse differentials between extremities 1, 2
• Pneumothorax: Dyspnea and pain on inspiration, unilateral absence of breath sounds 1

Serious But Non-Immediately Fatal Causes

• Pericarditis: Sharp, pleuritic chest pain worsening when supine, improving when leaning forward, friction rub on examination 1, 2
• Valvular disease: Aortic stenosis (systolic murmur, tardus/parvus carotid pulse), aortic regurgitation (diastolic murmur), hypertrophic cardiomyopathy 1

Common Benign Causes (Most Likely with Chronic Intermittent Right-Sided Pain)

• Costochondritis/Tietze syndrome: Tenderness of costochondral joints on palpation, pain reproducible with chest wall pressure, accounts for majority of cases when cardiac causes excluded 1, 2, 6
• Musculoskeletal chest wall pain: Pain affected by palpation, breathing, turning, twisting, or bending 2, 6
• Gastroesophageal reflux/esophagitis: Burning retrosternal pain related to meals, relieved by antacids 2
• Gallbladder disease: Right upper quadrant tenderness, Murphy sign 1

Management Algorithm

If Low-Risk Features Present (Normal ECG, Reproducible Chest Wall Tenderness, No High-Risk Features):

• Conservative management with NSAIDs for costochondritis 3
• Reassurance and return precautions: Instruct patient to return immediately if pain becomes constant, radiates to arms/jaw, or is accompanied by dyspnea or diaphoresis 3
• Outpatient management is appropriate if physical examination reproduces pain with costochondral palpation, ECG is normal, and patient understands return precautions 3

If High-Risk Features Present or Diagnostic Uncertainty:

• Transfer urgently to emergency department by EMS (not personal automobile) if new ECG abnormalities, hemodynamic instability, or clinical evidence of acute coronary syndrome 1, 2, 4
• Initial treatment may include: Aspirin 75-500 mg, glyceryl trinitrate, and oxygen if required 1, 4
• Do not use nitroglycerin response as diagnostic criterion, as esophageal spasm and other conditions also respond to nitroglycerin 2

Additional Imaging Based on Clinical Suspicion:

• Chest radiograph: If concern for pneumonia, pneumothorax, or pulmonary pathology 5
• Echocardiogram: To assess left ventricular function and eliminate other cardiovascular causes if cardiac etiology suspected 1
• CT angiography: If aortic dissection or pulmonary embolism suspected based on clinical presentation 5

Common Pitfalls to Avoid

• Do not dismiss chest pain in women or elderly patients, as they frequently present with atypical symptoms 1, 2
• Do not rely on nitroglycerin response as diagnostic criterion for cardiac ischemia 2
• Do not delay transfer for office-based troponin testing if high-risk features present 1, 2
• Remember that 7% of patients with reproducible chest wall tenderness may still have acute coronary syndrome 3