What is the differential diagnosis for retrosternal chest pain?

Differential Diagnosis of Retrosternal Pain

Retrosternal pain requires immediate consideration of life-threatening cardiovascular causes first—specifically acute coronary syndrome, aortic dissection, pulmonary embolism, and pericarditis—followed by systematic evaluation of gastrointestinal, pulmonary, musculoskeletal, and psychological etiologies. 1, 2

Life-Threatening Causes (Evaluate First)

Cardiovascular

• Acute Coronary Syndrome (ACS): Pressure-type pain typically lasting ≥10 minutes, occurring at rest or with minimal exertion, radiating to arms/neck/jaw, accompanied by diaphoresis, dyspnea, or nausea 1
• Aortic Dissection: Sudden severe chest or back pain with pulse differential between extremities (30% sensitivity), widened mediastinum on chest X-ray 2
• Pulmonary Embolism: Tachycardia and dyspnea present in >90% of patients, pleuritic pain component 2
• Pericarditis: Pain increases in supine position, may have friction rub on examination 2
• Expanding Aortic Aneurysm 1

Non-Cardiovascular Life-Threatening

• Esophageal Rupture: Severe pain with painful, tympanic abdomen 2
• Tension Pneumothorax: Pleuritic pain with unilateral absence of breath sounds 2

Common Non-Life-Threatening Causes

Gastrointestinal (10-20% of chest pain presentations) 2

• Gastroesophageal Reflux Disease (GERD): Most common cause of noncardiac retrosternal pain; squeezing or burning quality, minutes to hours duration, occurs after meals or at night, worsens with stress, may respond to antacids 2, 3
• Esophageal Motility Disorders: Achalasia, distal esophageal spasm, nutcracker esophagus—present as squeezing retrosternal pain or spasm, often with dysphagia 2
• Peptic Ulcer Disease 1
• Pancreatitis 1
• Biliary Disease 1

Musculoskeletal (Most Common in Primary Care—42-51% of cases) 4, 5

• Costochondritis: Pain reproducible by palpation of costochondral joints 1, 2, 5
• Muscle Strain 2
• Cervical Radiculopathy 1
• Rib Fracture (occult trauma) 2

Pulmonary

• Pneumonia: Fever, egophony, dullness to percussion 2, 5
• Pleuritis: Pain with inspiration 1
• Pneumothorax: Pleuritic pain, unilateral breath sound absence 1, 2

Psychological

• Panic Disorder/Anxiety: Diagnosis of exclusion in patients with recurrent presentations and negative cardiac workup 1, 2
• Somatoform Disorders 1

Other

• Herpes Zoster: Painful rash in dermatomal distribution 1, 2
• Sickle Cell Crisis 1

Critical Clinical Distinctions

Key features increasing probability of ACS 1:

• Older age, male sex
• Positive family history of coronary artery disease
• Peripheral arterial disease, diabetes mellitus, renal insufficiency
• Prior myocardial infarction or coronary revascularization

Atypical presentations more common in 1:

• Older patients (≥75 years)
• Women
• Patients with diabetes mellitus, impaired renal function, or dementia
• May present as epigastric pain, indigestion, stabbing/pleuritic pain, or isolated dyspnea

Physical examination findings that reduce ACS probability 2:

• Chest tenderness on palpation
• Pain with inspiration

Common Pitfalls

1. Do not use nitroglycerin response as diagnostic criterion—esophageal spasm also responds to nitroglycerin 6

2. Women are at risk for underdiagnosis—they present with accompanying symptoms (nausea, fatigue, shortness of breath) more frequently than men, though chest pain remains the predominant symptom in ACS 6

3. "Atypical chest pain" is problematic terminology—use "cardiac," "possible cardiac," or "noncardiac" instead to avoid ambiguity 2

4. GERD can perfectly mimic myocardial ischemia—empirical PPI trial (double dose for >2 months) is reasonable after cardiac causes excluded 3

5. Esophageal disease accounts for symptoms in approximately 45% of patients with atypical chest pain, but does not exclude coexisting coronary disease 7