Chest Pain Differential Diagnosis

The differential diagnosis for chest pain is broad and can be categorized into several groups. Here's a breakdown of the potential causes:

• Single Most Likely Diagnosis

  • Acute Coronary Syndrome (ACS): This is often the first consideration in patients presenting with chest pain, especially if the pain is described as squeezing, pressure, or heaviness, and is associated with exertion or stress. The justification for this being the single most likely diagnosis is based on the high prevalence of coronary artery disease in the general population and the potential for serious outcomes if not promptly addressed.

• Other Likely Diagnoses

  • Gastroesophageal Reflux Disease (GERD): Chest pain that is burning in nature and associated with eating or lying down could suggest GERD. This condition is common and can mimic cardiac chest pain.
  • Musculoskeletal Pain: Pain that is sharp, localized to a specific area, and reproducible with movement or palpation may indicate a musculoskeletal origin, such as costochondritis or muscle strain.
  • Pulmonary Embolism (PE): While not as common as ACS, PE is a significant consideration, especially in patients with risk factors such as recent travel, immobilization, or a history of deep vein thrombosis. The pain is often described as sharp and stabbing, and may be accompanied by shortness of breath.
  • Pneumonia or Pleuritis: Infections or inflammation of the lung tissue or pleura can cause chest pain, typically sharp and worsened by deep breathing or coughing.

• Do Not Miss Diagnoses

  • Aortic Dissection: A life-threatening condition where the inner layer of the aorta tears, causing severe, tearing chest pain that radiates to the back. It's crucial to consider this diagnosis, especially in patients with hypertension or a history of aortic aneurysm.
  • Pulmonary Embolism (also listed under Other Likely Diagnoses): Due to its potential for high mortality if missed, PE is emphasized again here.
  • Esophageal Rupture: A rare but deadly condition that can cause severe chest pain, often after forceful vomiting or retching.

• Rare Diagnoses

  • Pericarditis: Inflammation of the pericardium, the sac surrounding the heart, can cause sharp, stabbing chest pain that improves with sitting up and leaning forward.
  • Pneumothorax: Air in the pleural space can cause sharp chest pain and shortness of breath, often in patients with underlying lung disease or after trauma.
  • Myocarditis: Inflammation of the heart muscle, which can cause chest pain, arrhythmias, and signs of heart failure, often following a viral infection.

Each of these diagnoses has distinct characteristics and risk factors that can guide the clinician towards the correct diagnosis. A thorough history, physical examination, and appropriate diagnostic tests are essential for accurately diagnosing the cause of chest pain.