Differential Diagnosis for Chest Pain with Normal EKG

When a patient presents with chest pain but has a normal electrocardiogram (EKG), it's crucial to consider a broad range of potential causes, as the presentation can be deceptive. The differential diagnosis can be organized into the following categories:

• Single Most Likely Diagnosis
  • Gastroesophageal Reflux Disease (GERD): This is often the most common cause of chest pain in patients with a normal EKG. The pain can mimic cardiac ischemia but is usually related to acid reflux.
• Other Likely Diagnoses
  • Musculoskeletal Pain: Costochondritis or musculoskeletal strain can cause chest pain that is not related to cardiac issues.
  • Pulmonary Embolism: Although less common, pulmonary embolism can present with chest pain and a normal EKG, especially if the embolism is small or peripheral.
  • Pneumonia or Pleuritis: Inflammation of the lung or pleura can cause chest pain that worsens with breathing.
• Do Not Miss Diagnoses
  • Aortic Dissection: A life-threatening condition where the inner layer of the aorta tears. It can present with chest pain and a normal EKG, making it a critical diagnosis not to miss.
  • Myocardial Infarction with Normal EKG: Some myocardial infarctions, especially those involving the posterior or right ventricle, may not show typical changes on a standard EKG.
  • Pulmonary Hypertension: Can cause chest pain due to right ventricular strain and may have a normal EKG.
• Rare Diagnoses
  • Pericarditis: Inflammation of the pericardium, which can cause chest pain. While an EKG may show changes in pericarditis, such as widespread ST elevation, some cases may have a normal EKG.
  • Esophageal Spasm or Rupture: These conditions are less common but can cause severe chest pain.
  • Chest Wall Trauma: Even minor trauma can cause significant pain if it involves the musculoskeletal structures of the chest wall.

Each of these diagnoses requires careful consideration based on the patient's history, physical examination, and additional diagnostic tests as needed. The key to managing chest pain with a normal EKG is to maintain a high index of suspicion for serious conditions while also considering more common, less dangerous causes.