Differential Diagnosis for Left and Mid-Sternal Chest Pain Radiating to Back

Single Most Likely Diagnosis

• Acute Coronary Syndrome (ACS): This condition, which includes myocardial infarction (MI), is a leading cause of chest pain and can radiate to the back. The pain is often described as squeezing or pressure and can be exacerbated by exertion or position. Although the classic presentation does not always include radiation to the back, it is a common enough variation to make ACS a top consideration.

Other Likely Diagnoses

• Gastroesophageal Reflux Disease (GERD): GERD can cause chest pain that radiates to the back, worsens with position (especially lying down), and can be exacerbated by eating certain foods. The absence of skin lesions does not rule out GERD.
• Musculoskeletal Pain: Strain or inflammation of the muscles or joints in the chest wall can cause pain that radiates to the back. This type of pain often worsens with movement or position.
• Pulmonary Embolism (PE): While PE typically presents with sudden onset dyspnea, it can also cause chest pain that worsens with deep breathing (pleuritic chest pain) and can radiate to the back. The absence of skin lesions does not rule out PE.

Do Not Miss Diagnoses

• Aortic Dissection: A life-threatening condition where the inner layer of the aorta tears, causing severe, tearing chest pain that can radiate to the back. It is crucial to consider this diagnosis, even if it seems unlikely, due to its high mortality rate if missed.
• Pneumothorax: Air in the pleural space can cause sudden, severe chest pain that worsens with position and deep breathing. Although skin lesions are not typically associated with pneumothorax, it is a critical diagnosis not to miss due to its potential for rapid deterioration.

Rare Diagnoses

• Esophageal Spasm or Rupture: These conditions can cause severe chest pain that radiates to the back. Esophageal rupture is a medical emergency, but both conditions are less common than other causes of chest pain.
• Spinal or Thoracic Vertebral Fracture: Osteoporotic or traumatic fractures of the spine can cause severe back pain that radiates to the chest. This would be an unusual presentation but should be considered, especially in patients with risk factors for osteoporosis or recent trauma.
• Pericarditis: Inflammation of the pericardium can cause sharp, stabbing chest pain that can radiate to the back and worsen with position. It is less common than other causes of chest pain but can be serious if not treated.