Differential Diagnosis for Chest Pressure that is not an MI

The following differential diagnosis is organized into categories to help guide the thought process.

• Single most likely diagnosis

  • Gastroesophageal Reflux Disease (GERD): This is a common condition that can cause chest pressure or discomfort, often related to eating or lying down. The symptoms can mimic those of an MI, but the presence of heartburn, regurgitation, or relief with antacids can help differentiate GERD from cardiac causes.

• Other Likely diagnoses

  • Anxiety or Panic Disorder: Chest pressure or tightness is a common symptom in anxiety and panic attacks. A history of anxiety, presence of other symptoms like palpitations, shortness of breath, or fear of dying, and relief with anxiolytics can suggest this diagnosis.
  • Musculoskeletal Pain: Strain or inflammation of the muscles or joints in the chest wall can cause localized pain or pressure. History of trauma, movement-related pain, or tenderness to palpation can indicate musculoskeletal causes.
  • Asthma or Chronic Obstructive Pulmonary Disease (COPD) Exacerbation: These conditions can cause chest tightness or pressure, especially during exacerbations. A history of respiratory disease, wheezing, cough, or shortness of breath can point towards these diagnoses.
  • Pulmonary Embolism (PE): While not as common as other causes, PE can present with chest pressure, especially if it is large or involves multiple segments. Risk factors for thromboembolism, such as recent travel, surgery, or immobilization, and symptoms like sudden onset dyspnea or tachycardia, can suggest PE.

• Do Not Miss diagnoses

  • Aortic Dissection: A life-threatening condition where the inner layer of the aorta tears. It can present with severe, tearing chest pain that radiates to the back. Risk factors include hypertension, aortic aneurysm, or connective tissue disorders like Marfan syndrome.
  • Pneumothorax: Air in the pleural space can cause chest pressure or pain, especially if it is a tension pneumothorax. Symptoms like shortness of breath, decreased breath sounds on one side, or recent trauma can indicate pneumothorax.
  • Pericarditis: Inflammation of the pericardium can cause sharp, stabbing chest pain that improves with leaning forward. A history of recent viral illness, fever, or pericardial friction rub can suggest pericarditis.

• Rare diagnoses

  • Esophageal Spasm or Esophageal Rupture: These conditions can cause severe chest pain. Esophageal spasm is often related to swallowing or eating, while esophageal rupture is a medical emergency with severe pain, often following forceful vomiting.
  • Costochondritis (Tietze's Syndrome): Inflammation of the cartilages and bones in the chest wall can cause localized pain and tenderness, often mimicking cardiac pain but with specific points of tenderness.
  • Pneumomediastinum: Air in the mediastinum can cause chest pain or pressure, often following procedures like endoscopy or in the context of lung disease.