Differential Diagnosis for Chest Pain: Costochondritis vs ACS

When evaluating chest pain, it's crucial to differentiate between costochondritis and acute coronary syndrome (ACS) due to their vastly different implications and treatments. Here's a structured approach to the differential diagnosis:

• Single Most Likely Diagnosis

  • Costochondritis: This condition, characterized by inflammation of the cartilage that connects the ribs to the breastbone, is a common cause of chest pain, especially in younger individuals or those without risk factors for coronary artery disease. The pain is typically sharp, localized to the costosternal junctions, and can be reproducible with palpation or movement.

• Other Likely Diagnoses

  • Musculoskeletal pain: Conditions such as muscle strain or rib fractures can cause chest pain similar to costochondritis but may have different triggers and characteristics.
  • Gastroesophageal reflux disease (GERD): GERD can cause chest pain that may mimic ACS or costochondritis, especially if the pain is burning in nature and associated with eating or regurgitation.
  • Pneumonia or pulmonary embolism: While these conditions have distinct features (such as fever, cough, or shortness of breath), they can occasionally present with isolated chest pain and must be considered, especially in high-risk patients.

• Do Not Miss Diagnoses

  • Acute coronary syndrome (ACS): Including myocardial infarction (MI), ACS is a medical emergency that requires immediate intervention. The pain is typically described as a pressure or heaviness in the chest, radiating to the arm, neck, or jaw, and may be accompanied by shortness of breath, diaphoresis, or nausea.
  • Aortic dissection: A life-threatening condition where the inner layer of the aorta tears, causing severe, tearing chest pain that radiates to the back.
  • Pulmonary embolism: A blockage of an artery in the lungs that can cause sudden, severe chest pain, especially with deep breathing, accompanied by shortness of breath and possibly cough or hemoptysis.

• Rare Diagnoses

  • Pericarditis: Inflammation of the pericardium, the sac surrounding the heart, which can cause sharp, stabbing chest pain that improves with sitting up and leaning forward.
  • Esophageal rupture or perforation: A severe condition that can cause sudden, severe chest pain, often associated with difficulty swallowing, vomiting, or severe retching.
  • Pneumothorax: Collapse of the lung due to air in the pleural space, which can cause sudden, severe chest pain and shortness of breath, especially if large.

Each of these diagnoses has distinct features and risk factors that can guide the clinician towards the correct diagnosis. A thorough history, physical examination, and judicious use of diagnostic tests (such as ECG, troponin levels, chest X-ray, and CT scans) are essential for distinguishing between these conditions and ensuring timely and appropriate treatment.