When to Be Concerned About Right Sided Chest Pain

Causes and Diagnosis

woman in pain with her hand over the right side of her chest
What are the possible causes of right sided chest pain?. Istockphoto.com/Stock Photo©michaeljung

We hear a lot about left-sided chest pain and its relationship to heart disease, but what about right-sided chest pain? What causes this symptom? And, most importantly, when should you be worried?

Any Chest Pain Can Be An Emergency

It’s important to note right away that chest pain in any location could be related to heart disease or other serious problems. If your pain is severe, if you are feeling short of breath, or if your gut is telling you something is seriously wrong, call 911 right away. It’s better to err on the side of mistakenly calling for help when you don't need it than to miss calling for help when you need it. If you're still not certain, check out these clues as to when chest pain is an emergency.

Right Sided Chest Pain and Heart Disease

Pain that occurs primarily on the right side of your chest has many possible causes just as does left sided chest pain. It's important to note right away, as in the warning note above, that pain on the right side of the chest can be due to heart disease. Classically, the pain associated with heart disease occurs on the left side and central area of the chest, but there are many exceptions.

Pain that is felt only on the right side of the chest may occur with any type of heart attack, but especially those that affect the right side of the heart. In fact, since heart attacks involving the right coronary artery tend not to be as quickly fatal as some of those on the left side (such as blockages of the left anterior descending artery or "widow maker") a person may be less likely to recognize he or she is having a heart attack and needs immediate help.

It's also important to keep in mind that cardiac symptoms in women are often different than in men. Women are less likely to experience the classic left sided chest pain and instead may note a burning sensation on either side of the chest or even no pain at all. If in doubt, immediately check it out.

Right Sided Chest Pain as an Emergency

In addition to the possibility that right-sided chest pain could be a sign of a heart attack, there are other emergencies that may present with right-sided chest pain as well. These include pulmonary emboli (blood clots in the legs that break off and travel to the lungs) and dissecting aortic aneurysms. These conditions require emergency treatment as well. If you have noticed the sudden onset of sharp chest pain, a tearing sensation in your chest, sudden onset of shortness of breath, or lightheadedness, read no further and call 911.

Right Sided Chest Pain: Anatomy 

If you have pain on the right side of your chest you may first think about what "lives" on the right side of your chest cavity or "thorax."

This area is home to a portion of the right side of the heart, the right lung (three lobes), large blood vessels such as the ascending aorta and pulmonary blood vessels, the esophagus, and other structures such as lymph nodes, and nerves. The ribs lie in this region, and disorders of the spine may be felt in this region as well.

Pain that is felt on the right side may be due to a problem in that particular area or instead can be due to referred pain. With referred pain, pressure or damage to a nerve that runs through the chest may cause pain to be felt at a location some distance from where the pain actually originates.

Upper abdominal disorders may be felt on the right side of the chest, and if the diaphragm is irritated, this may be associated with pain in the right shoulder as well. The liver, the gallbladder, and part of the pancreas lie in this region.

In an uncommon condition affecting around one in 10,000 people, situs inversus, the organs of the chest cavity and sometimes other structures are reversed in their location, so that sometimes the heart is found on the right side of the body.

Description of Symptoms 

A list of some of the questions your doctor may ask is noted below. She will want you to describe the character of your pain, whether severe or mild, sharp or dull and any other features. The letters OPQRST are often used as a way to remember the important aspects of chest pain to consider:

  • O - Onset - How long have you had the pain?
  • P - Provocation - Is there anything that makes the pain worse, such as moving or a taking a deep breath?
  • Q - Quality - What does the pain feel like? Is it sharp or dull?
  • R - Radiation - Does the pain radiation anywhere, such as to your back, your neck, your jaw, or your shoulder?
  • S - Severity - On a scale of one to 10 with one being barely there and 10 being the worse pain you can imagine, how severe is your pain?
  • T - Time - How long have you had the pain?

Associated Symptoms

In addition to the quality of your pain, it is important to take note of any symptoms you have in addition to right-sided chest pain. These symptoms may include:

Possible Causes of Right Sided Chest Pain

The causes of right-sided chest pain are similar to left-sided chest pain but there are some conditions which are more likely to be felt on one side or the other.  Some of the possible causes broken down by body systems are listed below.

Musculoskeletal Causes

With trauma, fractures and damage to soft tissue such as muscles and ligaments can cause chest pain. Without a history of trauma, there are several conditions which may also give rise to right-sided chest pain. Some of these include:

  • Costochondritis Costochondritis is a condition in which there is inflammation of the cartilage where the ends of the ribs join with the sternum (the costochondral junction.) It is usually caused by a chronic overuse type of injury so most people do not recall any specific trauma. The pain tends to worsen with activity or with a deep breath, and there is often tenderness when pressure is placed over the rib junctions. A less common problem, Tietze's syndrome is similar but includes swelling and usually involves only one rib.
  • Muscle strain - Muscle strains are one of the more common causes of right-sided chest pain. Many people can recall activities such as heavy lifting or a new workout program that they engaged in before developing this type of pain.
  • Chest wall pain - There are many conditions which may cause chest wall pain in addition to costochondritis ranging from fibromyalgia to stress fractures to sickle cell crisis.
  • Cervical or thoracic spine conditions - Conditions such as disc disease or compressed vertebrae may cause pain that is felt on the right side of the chest, either due to the location of a condition or due to referred pain from involved nerves. Sometimes metastases to the spine from breast cancer, lung cancer, and other tumors are first noted as chest pain on the right side.

    Heart and Blood Vessel Related Causes

    As noted above, angina, a heart attack, or other conditions may lead to pain anywhere in the chest including the right side. Some other heart and blood vessel related conditions which may cause right-sided chest pain include:

    • Coronary artery disease - As noted earlier, heart disease may cause pain on both sides of the chest or only on the right side. This is more commonly found with conditions involving the right side of the heart.
    • Pericarditis - Pericarditis is an inflammation of the pericardium, the protective membrane surrounding the heart. There are many causes of pericarditis ranging from infections to cancer treatment, to kidney disease, to autoimmune disorders such as rheumatoid arthritis. It is also common after people have had a heart attack. The pain is often worse in certain positions and becomes more intense with a deep breath.
    • Dissecting aortic aneurysm - A dissecting aortic aneurysm occurs when a tear in the aorta allows blood to flow between the layers of the blood vessel wall and dissects or tears the blood vessel. The pain is often severe, sudden, and sharp, and may be described as a tearing pain. Unconsciousness may follow rapidly. Perhaps best remembered as the form of trauma Princess Diana sustained, it may also occur without any trauma in people with high blood pressure or connective tissue conditions such as Marfan syndrome.

      Lung Related Causes

      The three lobes of the right lung, as well as the lining of the right lung and associated lymph nodes, are located on the right side of the chest. The lungs themselves do not have pain receptors, but you may still experience pain that "feels" like it is in your right lung. Possible causes of pain may include:

      • Pulmonary emboli - Pulmonary emboli occur when blood clots in the legs (deep venous thrombosis) break off and travel toward the lungs. If the clot lodges in vessels of the right lung, pain may occur. This pain is often sudden and sharp and may be associated with severe shortness of breath. With large clots, unconsciousness may follow rapidly. People may or may not recall having pain, redness, or swelling in one or both legs prior to a pulmonary embolus. Unfortunately, pulmonary emboli are very common, occurring in over half a million people each year. They are fatal around 10 percent of the time. Risk factors include many chronic diseases, prolonged bed rest or surgery, and long-distance travel by plane or by car, yet a significant number of people do not have any obvious risk factors.
      • Lung cancer - Tumors in the right lung, the lining of the right lung, or nearby lymph nodes can cause pain on the right side of the chest. Roughly half of people, looking back, have some pain in the chest, in their shoulder blades or pain between the shoulder blades, or into their shoulders, prior to diagnosis of lung cancer. Other symptoms may be present such as shortness of breath or a persistent cough. Since lung cancer is often diagnosed in the later stages after it has spread, it is important to have any unexplained pain on the right side of your chest evaluated.
      • Other tumors - Tumors other than lung cancer may occur in the chest cavity as well, particularly lymphomas. In addition, metastases (spread) from other cancers such as breast cancer and colon cancer may occur to the lungs.
      • Pneumonia - Pneumonia, especially infections of your right lung could cause chest pain on the right side of your chest. People with pneumonia often, but not always, have a fever and cough.
      • Pneumothorax - A collapse of a lung called a pneumothorax may occur and cause pain on the right side of the chest.
      • Pleural effusions - A pleural effusion is a build-up of fluid in the space between the pleural membranes surrounding the lungs. There are many causes of pleural effusions. When an effusion is small, there may only be discomfort, but with large effusions shortness of breath is often present as well. With lung cancer and breast cancer, cancerous pleural effusions (malignant pleural effusions) can be quite painful.
      • Pleurisy (Pleuritic chest pain) - Inflammation of the linings of the lung, called the pleura, can cause often persistent right sided chest pain. This pain often increases with a deep breath and can sometimes feel scratchy.

        Digestive Tract Causes

        Abdominal conditions, especially those involving the esophagus or organs on the right side of the abdomen such as the gallbladder and liver may cause pain restricted to the right side of the chest. Some conditions which may cause right-sided chest pain include:

        • Gastroesophageal reflux disease (GERD)GERD may cause classic symptoms of heartburn and indigestion, but may also be felt as pain in the right side of the chest alone. 
        • Esophageal foreign body - A cause of right-sided chest pain that is sometimes overlooked is that of an esophageal foreign body. If your symptoms began while eating, especially meats, make sure to let your doctor know.
        • Esophageal spasm - Esophageal spasm can cause right sided chest pain. Pain from esophageal spasm may be easily confused with that from heart disease as it often improves with nitroglycerine.
        • Gallbladder disease - Both gallstones and cholecystitis, an infection of the gallbladder may be felt as right-sided chest pain. This pain often radiates through to the back and may also radiate to the right shoulder.  
        • Pancreatitis - The pain associated with pancreatitis can be worse with lying down and better with sitting up. People with diabetes and excess alcohol intake are at an increased risk.
        • Peptic ulcer disease/gastritis - Both peptic ulcer disease and gastritis may cause pain which is felt in the right side of the chest, though it is more common on the left. The pain may initially actually improve somewhat with eating.
        • Liver disease - Liver diseases such as hepatitis, cirrhosis, and even tumors which have spread to the liver (metastases) may cause pain which is felt in the right side of the chest. There is sometimes associated jaundice, a yellowish discoloration of the skin and the whites of the eyes.

        Other Causes 

        There are several other possible causes of pain in the right side of the chest. Some of these include:

        • ShinglesShingles is a condition which occurs when the chickenpox virus (which lives in nerve roots) is reactivated. If the virus has been lying dormant in nerve roots supplying the right side of the chest, pain may occur in this region. A rash usually occurs in the distribution of the nerve roots and helps to make the diagnosis, but the pain may precede the rash by several days making the diagnosis at first difficult.
        • Mediastinal tumors - Tumors or enlarged lymph nodes in the mediastinum, the area of the chest between the lungs, can cause chest pain felt on either side of the chest but may occur only on the right side. Enlargement of the mediastinal lymph nodes may occur with both Hodgkin's disease and non-Hodgkin's lymphomas as well as from the spread of lung cancer or breast cancer. Thymomas, bronchogenic cysts, and other benign tumors may occur in this region.
        • Breast pain - If pain due to a breast condition occurs deep in the breast it may feel like the pain lies deeper in the chest. 
        • Anxiety and panic disorder - About 40 percent of people with panic disorder experience frightening chest pain at some time. Atypical chest pain associated with panic disorder is unique in some ways, but you always want to err on the side of caution. People who have anxiety or even panic disorder can also experience life-threatening causes of chest pain.

        Tests Your Doctor May Order

        Depending on your symptoms and other factors, there are several tests your doctor may order. The first thing she will do is to make sure your "ABC's" are stable. This stands for airway, breathing, and circulation, essentially the function of your heart and lungs. If you appear stable she will then ask you many questions (take a careful history looking for any risk factors) and do a physical exam.

        Some conditions can be diagnosed during a physical exam, for example, tenderness over the joint between your ribs and sternum may suggest costochondritis or a classic rash may suggest shingles.

        Other tests may include:

        Questions Your Doctor May Ask

        Your doctor will ask you many questions to try and narrow down the possible causes of your symptoms. If you are waiting to see your doctor, you may want to write down anything that comes to mind so you can give her as many "clues" as possible. Questions may include:

        • When did your pain begin? Have you ever had the pain before?
        • Did the pain begin rapidly or did it come on gradually? Did it come on with activity or at rest? Were you eating when the pain began?
        • How would you describe the pain? Is it sharp or dull, mild or severe, or does it have any other characteristics such as a tearing feeling, burning, crushing, or squeezing?
        • Does anything make your pain worse or make it better?
        • Does the pain get worse with breathing or with eating?
        • Does the pain radiate (move) anywhere, such as to your back, your jaw, or elsewhere?
        • Where exactly is the pain located? Is it is a specific area or is it diffuse across your chest?
        • What other symptoms have you had, for example, shortness of breath, a persistent cough, hoarseness, unexplained weight loss, difficulty swallowing, nausea or vomiting, or jaundice?
        • What other medical conditions do you have?
        • Are you on any prescription medications or do you take any over-the-counter medications or nutritional supplements?
        • Do you smoke or have you ever smoked?
        • How much alcohol do you drink?
        • What medical problems run in your family?

        When to Call Your Doctor or 911

        If your pain is severe, if you have developed sudden shortness of breath, lightheadedness, you should call 911 right away.

        Bottom Line

        Right-sided chest pain is not as likely as left-sided chest pain to be related to heart disease, but that doesn't mean it is any less serious. If your pain is severe or if you're noticing shortness of breath, or even wonder if your symptoms could be life-threatening don't wait. Call 911.

        If you will be seeing your doctor, consider the questions above. Finding the source of right-sided chest pain is sometimes like putting together a puzzle, and the more puzzle pieces available, the easier it sometimes is to solve.

        If you're not getting answers, keep asking questions. Pain is a message to our minds that something is wrong. If it's lasting, talk to your doctor again. Sometimes further testing is needed, for example, one in four people with lung cancer had normal chest x-rays at the time of diagnosis, and a CT scan was needed to find the tumor. At the same time, lung cancer is the leading cause of cancer deaths in men and women in the United States, and lung cancer in never smokers is the 6th leading cause of cancer-related deaths. If you still don't have answers, ask for a second opinion.

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