What is the cause of intermittent pulsating in the chest near the right sternal border?

Intermittent Pulsating in Chest Near Right Sternal Border

The most likely cause of intermittent pulsating near the right sternal border is a normal finding from visualization of the ascending aorta or right ventricular outflow tract, though you must systematically exclude serious cardiac pathology including aortic valve disease, right ventricular involvement in inferior MI, and pulmonary hypertension. 1

Initial Assessment Priority

Your immediate focus should be on excluding life-threatening causes through:

• Vital signs assessment including blood pressure in both arms (to evaluate for aortic dissection if pulse differential exists), heart rate, and respiratory rate 1
• Cardiovascular examination focusing on:
  • Auscultation at the right upper sternal border for aortic stenosis murmur or aortic regurgitation 1
  • Assessment for accentuated P2 suggesting pulmonary hypertension 1
  • Evaluation of S2 splitting pattern—a normally split S2 that widens with inspiration reliably excludes severe aortic stenosis 2
  • Palpation of the precordium to characterize the pulsation quality and timing 1

Differential Diagnosis by Location

Cardiac Causes at Right Sternal Border

Aortic valve pathology is the primary cardiac concern at this location:

• Aortic stenosis produces a harsh systolic murmur at the right upper sternal border; severe stenosis results in a soft or absent A2 component of S2 1, 2
• Aortic regurgitation occurs in 40-75% of type A aortic dissections and produces a characteristic diastolic murmur 1

Right ventricular pathology can manifest as visible pulsations:

• Right ventricular infarction (associated with inferior MI) causes the ST-segment vector to direct anteriorly and rightward, producing ST elevation in right-sided chest leads V3R and V4R 1
• Pulmonary hypertension produces an accentuated P2 and may cause visible right ventricular impulse 1

Non-Cardiac Causes

Musculoskeletal origins are common and benign:

• Costochondritis accounts for 42% of nontraumatic musculoskeletal chest wall pain and is diagnosed by tenderness to palpation of costochondral joints 1
• Chest wall pain is reproducible by palpation and typically localized 3

Vascular structures can produce visible pulsations:

• The ascending aorta courses near the right sternal border and can be visible in thin individuals or with aortic dilation 1
• The abdominal aorta pulse can be palpated at the umbilicus level, though this is lower than your described location 1

Diagnostic Algorithm

Step 1: Characterize the Pulsation

• Timing: Systolic pulsations suggest arterial origin; continuous suggests venous 1
• Respiratory variation: Right-sided cardiac sounds and pulsations increase with inspiration 4
• Reproducibility: If palpation of the chest wall reproduces or alters the sensation, consider musculoskeletal origin 3

Step 2: Perform Targeted Examination

• Auscultate specifically for murmurs at the right upper sternal border (aortic area) 1
• Assess S2 splitting pattern during respiration 2
• Check for pulse differentials between extremities if dissection is suspected 1
• Palpate costochondral junctions for tenderness 1

Step 3: Obtain 12-Lead ECG

• Look for ST-segment elevation or depression suggesting acute coronary syndrome 1
• Evaluate for left ventricular hypertrophy or bundle branch blocks that increase cardiac risk 1
• A completely normal ECG does not exclude acute coronary syndrome but significantly reduces probability 1

Step 4: Risk Stratification

High-risk features requiring urgent evaluation include: 1

• Associated chest pain, dyspnea, or syncope
• Abnormal vital signs (hypotension, tachycardia)
• New murmurs or abnormal heart sounds
• ECG abnormalities

Low-risk features suggesting benign etiology include: 3

• Isolated pulsation without other symptoms
• Reproducible with palpation
• Normal cardiovascular examination
• Normal ECG

Common Pitfalls to Avoid

• Do not dismiss pulsations in patients with cardiovascular risk factors even if the examination seems benign; obtain ECG and consider echocardiography 1
• Do not assume musculoskeletal origin without systematic cardiac evaluation, as chest wall tenderness can coexist with cardiac disease 1
• Do not rely solely on patient description of "pulsating"—palpitations are subjective and require objective correlation with examination findings 5, 6
• Remember that right ventricular infarction presents with inferior MI and requires right-sided chest leads (V3R, V4R) for diagnosis—these ST elevations are transient and must be captured early 1

When to Pursue Advanced Testing

Echocardiography is indicated when: 1

• Murmurs are detected on examination
• S2 is single or paradoxically split
• Clinical suspicion for structural heart disease exists
• Pulsations are associated with symptoms

Ambulatory ECG monitoring is appropriate if: 6

• Pulsations are intermittent and unpredictable
• Associated palpitations occur
• Initial evaluation is unrevealing but symptoms persist