What is the differential diagnosis for a patient presenting with chest tightness and cough?

Differential Diagnosis for Chest Tightness and Cough

The differential diagnosis for chest tightness and cough should systematically address the most common causes first—upper airway cough syndrome (UACS), asthma, non-asthmatic eosinophilic bronchitis (NAEB), and gastroesophageal reflux disease (GERD)—while simultaneously ruling out life-threatening conditions including pneumonia, pulmonary embolism, acute coronary syndrome, and heart failure. 1, 2

Immediate Life-Threatening Conditions to Exclude

Pneumonia

• Suspect when acute cough occurs with new focal chest signs, dyspnea, tachypnea, or fever lasting >4 days 1
• Obtain chest radiograph (posteroanterior and lateral views preferred) to confirm diagnosis 1, 2
• Elderly patients (>65 years) may present with atypical features and still warrant chest imaging despite normal vital signs 1

Pulmonary Embolism

• Consider in patients with history of deep vein thrombosis or pulmonary embolism, immobilization in past 4 weeks, or malignant disease 1
• Can present with simple acute cough and chest tightness, making it difficult to distinguish from respiratory tract infection 1

Acute Coronary Syndrome

• Age, sex, and chest pain characteristics predict likelihood of coronary artery disease 3
• Obtain 12-lead electrocardiography looking for ST segment changes, new left bundle branch block, Q waves, or new T-wave inversions 3

Cardiac Failure

• Suspect in patients >65 years with orthopnea, displaced apex beat, and/or history of myocardial infarction 1
• Can present with cough and chest tightness mimicking respiratory conditions 1

Common Causes of Chronic Cough and Chest Tightness

Upper Airway Cough Syndrome (UACS)

• Most common cause of chronic cough, representing 61-67% of cases in referral settings 1
• Previously termed postnasal drip syndrome 1

Asthma and Chronic Airway Disease

• Consider when patient has ≥2 of: wheezing, prolonged expiration, smoking history, symptoms of allergy 1
• Up to 45% of patients with acute cough >2 weeks may have undiagnosed asthma or COPD 1
• Perform spirometry with bronchodilator testing to assess for obstructive lung disease 2

Gastroesophageal Reflux Disease (GERD)

• One of the four most common causes requiring systematic empiric treatment 1
• Often coexists with other causes of chronic cough 1

Non-Asthmatic Eosinophilic Bronchitis (NAEB)

• Should be considered in the systematic evaluation of chronic cough 1

Medication-Induced Causes

ACE Inhibitor-Induced Cough

• Immediately inquire about ACE inhibitor use as this is a common and reversible cause 2
• Switch to another drug class if identified 2
• Consider therapeutic trial of withdrawing suspected causative drug 1

Beta-Blocker Exacerbation

• May exacerbate asthma and cause chest tightness 2

Less Common but Important Causes

Bronchiectasis

• Identified in 8-12% of chronic cough cases in referral settings 1
• Chest CT is reference standard for diagnosis 1

Interstitial Lung Disease

• Found in 8% of chronic cough referral cases 1
• May require chest CT for diagnosis as chest radiograph has limited sensitivity 1

Post-Infectious Cough (Subacute)

• Consider pertussis if cough persists >2 weeks with paroxysms, post-tussive vomiting, or inspiratory whooping 2, 4
• Evaluate for transient bronchial hyperresponsiveness following viral infection 1

Aspiration Pneumonia

• Consider in patients with swallowing difficulties, cerebrovascular events, or psychiatric diseases 1
• Obtain chest radiograph 1

Malignancy

• Identified in 2 cases per 404 referrals in one series 1
• Chest radiograph indicated if risk factors present or known cancer elsewhere 2

Critical Pitfalls to Avoid

Multiple causes frequently coexist—therapy should be given in sequential and additive steps rather than stopping after identifying one etiology 1. The diagnosis of unexplained (idiopathic) cough should only be made after thorough diagnostic evaluation, specific treatment trials have failed, and uncommon causes have been ruled out 1.

Do not overlook cardiac causes in patients presenting with respiratory symptoms—cardiac failure can mimic respiratory tract infections and should be considered in the appropriate clinical context 1.