What is the most appropriate initial evaluation and management for a patient with right upper chest pain?

Right Upper Chest Pain: Initial Evaluation and Management

Immediate Life-Threatening Exclusions (First 10 Minutes)

Obtain a 12-lead ECG within 10 minutes and draw high-sensitivity cardiac troponin immediately, even though right-sided chest pain is less typical for cardiac ischemia, because approximately 13% of patients with atypical pain patterns still have acute myocardial ischemia. 1, 2

Critical Diagnostic Actions

• Measure vital signs in both arms; a systolic blood pressure difference >20 mmHg suggests aortic dissection, which can present with right-sided chest pain when involving the ascending aorta. 2, 3
• Perform a focused cardiovascular examination for diaphoresis, tachypnea (>20 breaths/min occurs in ~70% of pulmonary embolism), unilateral absent breath sounds (pneumothorax), new murmurs, and pulse differentials. 2, 3
• Assess for Murphy's sign (right upper quadrant tenderness with inspiratory arrest) because gallbladder disease can refer pain to the right chest. 1

Algorithmic Approach Based on Pain Location and Character

Step 1: Exclude Cardiac Causes First

• Do not dismiss acute coronary syndrome based solely on right-sided location; women and older adults frequently present with atypical pain patterns including right chest discomfort, jaw pain, nausea, or isolated dyspnea. 1, 2, 3
• If the ECG shows ST-elevation, ST-depression, or new ischemic changes, activate emergency medical services immediately and transport to a facility with 24/7 cardiac catheterization capability. 2, 3
• A normal initial ECG does not exclude myocardial infarction; 30-40% of acute MIs present with a normal or nondiagnostic first ECG. 2, 3
• Repeat high-sensitivity troponin at 1-3 hours (or conventional troponin at 3-6 hours) because a single normal result does not rule out acute coronary syndrome. 2, 3

Step 2: Evaluate for Pulmonary Embolism

• Right-sided pleuritic chest pain with sudden dyspnea and tachycardia (present in >90% of PE patients) mandates pulmonary embolism assessment. 2, 3
• Apply Wells criteria; obtain age- and sex-adjusted D-dimer for low-to-intermediate probability, or proceed directly to CT pulmonary angiography for high probability. 2, 3, 4

Step 3: Assess for Pneumothorax

• Sharp right chest pain that worsens with inspiration, accompanied by unilateral absent or markedly reduced breath sounds and hyperresonant percussion, indicates pneumothorax. 2, 3
• Tension pneumothorax presents with hemodynamic instability (hypotension, tachycardia) and tracheal deviation; this requires immediate needle decompression before imaging. 2, 3

Step 4: Consider Biliary and Hepatic Causes

• Right upper quadrant pain is most commonly caused by acute cholecystitis; ultrasound is the first-line imaging modality because it evaluates gallbladder wall thickening, pericholecystic fluid, gallstones, and bile duct dilation with high sensitivity. 1
• Ultrasound should be performed first even when complicated cholecystitis (emphysematous, hemorrhagic, gangrenous, or perforated) is suspected, though CT with IV contrast may be needed subsequently to detect complications such as gangrene, gas formation, or perforation. 1
• A positive Murphy sign (right upper quadrant tenderness with inspiratory arrest) supports biliary pathology. 1

Step 5: Evaluate Musculoskeletal Causes

• Pain reproducible with palpation of the right costochondral junctions or with chest wall movement (breathing, turning, twisting) suggests costochondritis, which accounts for approximately 43% of chest pain presentations after cardiac causes are excluded. 2, 3
• However, up to 7% of patients with reproducible chest wall tenderness still have acute coronary syndrome; therefore, palpable tenderness does not fully exclude cardiac disease. 2, 3

High-Risk Features Requiring Immediate Emergency Department Transfer

• Age >75 years with accompanying dyspnea, syncope, acute delirium, or unexplained falls. 1, 2, 3
• Hemodynamic instability (systolic BP <100 mmHg, heart rate >100 or <50 bpm). 2, 3
• Associated diaphoresis, severe dyspnea, nausea with vomiting, or light-headedness. 2, 3
• Any ECG abnormalities (ST-segment changes, T-wave inversions, new bundle branch block). 2, 3

Office/Outpatient Management Protocol

• If an ECG cannot be obtained on site, refer the patient to the emergency department immediately for ECG acquisition. 2, 3
• Do not delay emergency medical services transport for troponin testing when acute coronary syndrome, pulmonary embolism, or aortic dissection is suspected; immediate transport is essential because approximately 1.5% of chest pain patients develop cardiopulmonary arrest en route. 2, 3
• Administer chewed aspirin 162-325 mg while awaiting EMS unless contraindicated by allergy or active gastrointestinal bleeding. 2, 3

Common Pitfalls to Avoid

• Do not rely on nitroglycerin response to differentiate cardiac from non-cardiac chest pain; esophageal spasm, biliary colic, and other conditions may also improve with nitroglycerin. 1, 2, 3
• Avoid the term "atypical chest pain"; instead describe presentations as "cardiac," "possibly cardiac," or "non-cardiac" to prevent misinterpretation as benign. 1, 2, 3
• Do not assume a normal physical examination excludes life-threatening disease; uncomplicated myocardial infarction and early pulmonary embolism can present with entirely normal findings. 2, 3
• Sharp or pleuritic pain does not rule out acute coronary syndrome; approximately 13% of patients with pleuritic-type pain have acute myocardial ischemia. 2, 3

Disposition After Initial Workup

• Low-risk patients (normal ECG, negative troponin at presentation and 6-12 hours, stable vital signs, no ongoing pain) can be observed in a chest pain unit for 10-12 hours or discharged for outpatient stress testing or coronary CT angiography within 72 hours. 2, 3
• If right upper quadrant ultrasound is normal and cardiac causes are excluded, consider gastroesophageal reflux disease (burning pain related to meals, relieved by antacids) or empiric proton pump inhibitor trial. 2, 5