What is the workup for intermittent right-sided chest pain?

From the Guidelines

A workup for intermittent right-sided chest pain should begin with a thorough history and physical examination, followed by targeted diagnostic tests, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. The initial evaluation should include an electrocardiogram (ECG) to assess for cardiac causes, a chest X-ray to evaluate for pulmonary or skeletal abnormalities, and basic laboratory tests including complete blood count, basic metabolic panel, cardiac enzymes (troponin), and D-dimer if pulmonary embolism is suspected.

• The use of high-sensitivity troponin assays is now the global standard of care for identifying myocardial injury, as stated in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1.
• If these initial tests are inconclusive, further imaging may be necessary, such as a CT scan of the chest (with contrast if pulmonary embolism is suspected), or a CT coronary angiogram to evaluate coronary arteries, as suggested by the ACR Appropriateness Criteria for chest pain-possible acute coronary syndrome 1.
• For patients with risk factors for coronary artery disease, stress testing (exercise or pharmacological) may be appropriate, as recommended by the ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1.
• Depending on the clinical presentation, additional tests might include an echocardiogram to assess cardiac structure and function, pulmonary function tests if respiratory causes are suspected, or esophageal studies if gastroesophageal reflux is considered.
• Throughout this process, pain management may include acetaminophen 650mg every 6 hours or NSAIDs like ibuprofen 400-600mg every 6-8 hours if not contraindicated, as part of a patient-centered approach to care 1. This systematic approach is essential because right-sided chest pain can originate from cardiac, pulmonary, musculoskeletal, gastrointestinal, or psychological causes, and proper diagnosis guides appropriate treatment.
• The choice of diagnostic tests and treatment should be guided by the patient's risk factors, clinical presentation, and the results of initial diagnostic tests, as emphasized in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1.
• The use of clinical risk stratification tools, such as the HEART score, can help identify patients at low, intermediate, or high risk for acute coronary syndrome, and guide further diagnostic testing and treatment, as recommended by the ACR Appropriateness Criteria for chest pain-possible acute coronary syndrome 1.

From the Research

Initial Evaluation

• The workup for intermittent right-sided chest pain should begin with an electrocardiogram (ECG) obtained within 10 minutes of presentation, as recommended by 2.
• If ST-segment elevation is present on the ECG, ST-segment elevation myocardial infarction (STEMI) is diagnosed, and immediate management should be initiated.
• If STEMI is not present, troponin levels should be measured using one of several recommended protocols to evaluate for acute coronary syndrome (ACS) 2.

Risk Stratification

• If the ECG findings are normal and results of two troponin tests are negative, risk stratification should be calculated using the Thrombosis in Myocardial Infarction (TIMI) or HEART (History, ECG, Age, Risk factors, initial Troponin) score to determine the likelihood of coronary artery disease (CAD) 2.
• Based on the score, further evaluation to exclude CAD is completed during hospitalization or after discharge, using exercise treadmill testing, stress echocardiography, myocardial perfusion scintigraphy, or coronary computed tomography angiography.

Differential Diagnosis

• Pulmonary embolism (PE) should be considered in the differential diagnosis of intermittent right-sided chest pain, as it can present with similar symptoms and ECG findings to ACS 3, 4, 5.
• Echocardiography can be a useful tool in distinguishing PE from ACS, particularly in patients with atypical presentations 3, 4.
• A significant proportion of patients with PE may present with ECG changes suggestive of myocardial ischemia, including ST-segment depression or elevation, and elevated troponin levels 5.

Management

• Patients with suspected ACS should receive immediate management, including initiation of dual antiplatelet therapy and parenteral anticoagulation, statin therapy, beta-blocker therapy, and sodium-glucose cotransporter-2 inhibitor therapy 6.
• Coronary angiography with percutaneous or surgical revascularization should be considered for patients with ACS 6.
• Additional interventions, such as smoking cessation, annual influenza vaccination, and cardiac rehabilitation, can help reduce mortality in patients who have had a recent myocardial infarction 6.