Differential Diagnosis for Chest Pain in the Emergency Department

Single Most Likely Diagnosis

• Acute Coronary Syndrome (ACS): This is often the first consideration in patients presenting with chest pain, especially if they have risk factors such as hypertension, diabetes, high cholesterol, or a family history of heart disease. The presentation of ACS can vary from stable angina to myocardial infarction (MI), making it a broad yet critical diagnosis to consider.

Other Likely Diagnoses

• Pulmonary Embolism (PE): A common and potentially life-threatening condition that can present with sudden onset of chest pain, often accompanied by shortness of breath and possibly syncope. Risk factors include recent surgery, immobilization, cancer, and genetic predispositions to clotting.
• Pneumonia: Can cause chest pain, especially if the infection involves the pleura. Symptoms may include fever, cough, and shortness of breath.
• Gastroesophageal Reflux Disease (GERD): GERD and esophageal spasm can cause chest pain that may mimic cardiac ischemia. It's often associated with eating, lying down, and can be relieved by antacids.
• Musculoskeletal Pain: Strains, costochondritis, and other musculoskeletal issues are common causes of chest pain, often related to trauma, overuse, or inflammatory conditions.

Do Not Miss Diagnoses

• Aortic Dissection: A life-threatening condition where there is a tear in the aorta's inner layer. It presents with severe, tearing chest pain that can radiate to the back. Missing this diagnosis can be fatal.
• Pulmonary Embolism (also listed under Other Likely Diagnoses): Due to its high mortality rate if untreated, it's crucial not to miss PE, even though it's already considered among the likely diagnoses.
• Esophageal Rupture: A rare but critical condition that can occur after forceful vomiting or other esophageal injuries. It presents with severe chest pain and can lead to mediastinitis if not promptly treated.

Rare Diagnoses

• Pericarditis: Inflammation of the pericardium, which can cause sharp chest pain that improves with sitting up and leaning forward. It's less common but can be associated with viral infections, autoimmune diseases, or post-MI.
• Pneumothorax: Air in the pleural space can cause chest pain and shortness of breath. It's more common in tall, thin males or those with lung disease.
• Myocarditis: Inflammation of the heart muscle, often due to viral infections, can present with chest pain, heart failure symptoms, or arrhythmias. It's rare but can be serious.

Each of these diagnoses requires careful consideration based on the patient's history, physical examination, and diagnostic tests such as ECG, chest X-ray, and biomarkers (e.g., troponin for ACS). The approach to chest pain in the emergency department is highly protocolized to ensure that life-threatening conditions are identified and treated promptly.