Differential Diagnosis for Acute Chest Pain with History of Hypertension (HTN) and Hypercholesterolemia (HCL)

Single Most Likely Diagnosis

• Acute Coronary Syndrome (ACS): Given the patient's history of hypertension and hypercholesterolemia, which are significant risk factors for atherosclerotic heart disease, ACS (including myocardial infarction) is the most likely diagnosis. The acute onset of chest pain is a classic presentation.

Other Likely Diagnoses

• Pulmonary Embolism (PE): Although less likely than ACS, PE is a significant consideration, especially if the patient has additional risk factors such as recent immobilization, surgery, or a history of deep vein thrombosis.
• Acute Aortic Dissection: Hypertension is a major risk factor for aortic dissection, which can present with acute, severe chest pain. The pain is often described as tearing or ripping.
• Gastroesophageal Reflux Disease (GERD): GERD can cause chest pain that may be difficult to distinguish from cardiac causes, especially in patients with risk factors for heart disease.

Do Not Miss Diagnoses

• Pulmonary Embolism (PE): Already mentioned, but included here because it's crucial not to miss due to its high mortality rate if untreated.
• Acute Aortic Dissection: The consequences of missing this diagnosis are catastrophic, with high mortality rates if not promptly treated.
• Myocardial Infarction with Normal Coronary Arteries: This includes conditions like coronary artery spasm or myocarditis, which can present similarly to ACS but require different management.

Rare Diagnoses

• Pericarditis: Inflammation of the pericardium can cause chest pain, but it's less common and typically has a distinct presentation (sharp pain that improves with sitting up and leaning forward).
• Esophageal Rupture: A rare but serious condition that can cause severe chest pain, often associated with difficulty swallowing or vomiting.
• Pneumothorax: Although more common in certain populations (e.g., tall, thin males), a spontaneous pneumothorax can cause acute chest pain and is a diagnosis that should not be overlooked due to its potential for serious complications.