What are the potential causes and recommended treatments for upper chest pain that worsens with inhalation and laying down?

Upper Chest Pain with Inhalation and Laying Down

Immediate Life-Threatening Causes to Rule Out First

This presentation is highly suggestive of acute pericarditis, but you must immediately exclude acute coronary syndrome, pulmonary embolism, and aortic dissection before settling on a benign diagnosis. 1

Critical Red Flags Requiring Emergency Evaluation

• Activate emergency services immediately if the patient has crushing chest pain, diaphoresis, nausea, radiation to arm/jaw/neck, or symptoms interrupting normal activity—these suggest ACS despite the positional component 2
• Obtain an ECG within 10 minutes of medical contact to identify STEMI, new left bundle branch block, or ST-segment changes 1, 2
• Measure cardiac troponin as soon as possible, as ACS can present with atypical features and a completely normal physical examination in uncomplicated cases 1, 2

Differential Diagnosis by Clinical Pattern

Pericarditis (Most Likely Given Your Description):

• Sharp, pleuritic chest pain that increases in the supine position and improves when sitting forward 1
• Pain worsens with deep inspiration 1
• May have associated fever and pericardial friction rub on examination 1
• ECG shows diffuse ST-elevation (concave upward) in multiple leads, unlike the focal changes of MI 1

Pulmonary Embolism:

• Presents with tachycardia and dyspnea in >90% of patients 1, 2
• Pleuritic chest pain that worsens with inspiration 1
• Physical examination may reveal tachycardia but peripheral pulses remain intact 2
• Requires urgent chest imaging (CT pulmonary angiography) if suspected 1

Acute Coronary Syndrome:

• Typically presents as gradual onset retrosternal pressure/heaviness building over several minutes, NOT sharp pain 1
• Sharp chest pain that increases with inspiration and lying supine is unlikely related to ischemic heart disease 1
• However, ACS must still be excluded with ECG and troponin given the high mortality risk 1, 2

Aortic Dissection:

• Sudden onset of ripping chest pain radiating to the back 1
• May have pulse differential (30% of patients), but absence of pulse differential does NOT rule out dissection 1, 2
• Requires immediate CT or MRI imaging if suspected 1

Pneumothorax:

• Sudden onset dyspnea and pleuritic chest pain 1
• Unilateral absence of breath sounds on examination 1
• Chest X-ray confirms diagnosis 1

Musculoskeletal (Costochondritis):

• Tenderness to palpation of costochondral joints 1
• Pain reproduced by chest wall palpation 3
• Diagnosis of exclusion only after life-threatening causes ruled out 1

Recommended Diagnostic Approach

Step 1: Immediate Assessment (Within 10 Minutes)

• 12-lead ECG to identify STEMI, pericarditis pattern, or ischemic changes 1, 2
• Vital signs including oxygen saturation, blood pressure in both arms, heart rate, respiratory rate 1, 4
• Cardiac troponin (high-sensitivity if available) 1, 2

Step 2: Physical Examination Focus

• Auscultate for pericardial friction rub (scratchy, triphasic sound best heard at left sternal border with patient leaning forward) 1
• Check for unilateral decreased breath sounds (pneumothorax) 1
• Assess for pulse differentials between extremities (aortic dissection) 1
• Palpate costochondral joints for reproducible tenderness (musculoskeletal) 1

Step 3: Additional Testing Based on Initial Findings

• Chest X-ray for all patients without obvious ACS to identify pneumothorax, pneumonia, or pleural effusion 1
• Transthoracic echocardiography if hemodynamic disturbances, new murmurs, or suspected pericardial effusion 1
• CT angiography if aortic dissection or pulmonary embolism suspected 1
• Serial troponins at presentation and 3-6 hours later if initial troponin negative but ACS still suspected 1

Treatment Algorithm

If Pericarditis Confirmed (After Excluding ACS):

• NSAIDs (ibuprofen 600-800mg three times daily or aspirin 750-1000mg three times daily) as first-line therapy 1
• Colchicine 0.5-0.6mg twice daily (once daily if <70kg) for 3 months to reduce recurrence 1
• Avoid lying flat—maintain upright or forward-leaning position for symptom relief 1
• Restrict strenuous physical activity until symptoms resolve and inflammatory markers normalize 1

If ACS Cannot Be Excluded:

• Aspirin 250-500mg (chewable or water-soluble) immediately unless contraindicated 2, 4
• Transport by EMS to emergency department—do NOT delay for office-based testing 1, 2
• Continuous cardiac monitoring with resuscitation equipment available 2

If Pulmonary Embolism Suspected:

• Supplemental oxygen if saturation <90% 4
• Immediate anticoagulation with heparin or low-molecular-weight heparin pending imaging 1
• Urgent CT pulmonary angiography 1

Critical Pitfalls to Avoid

• Never assume positional chest pain excludes ACS—elderly patients and diabetics may present with atypical symptoms despite severe disease 2
• Do not rely on pain severity to determine urgency, as severity is a poor predictor of imminent complications like cardiac arrest 2
• Fleeting chest pain of few seconds' duration is unlikely ischemic, but pain lasting minutes requires full cardiac workup 1
• Do not diagnose musculoskeletal chest pain without first obtaining ECG and troponin to exclude life-threatening causes 1
• Avoid delayed transfer from office to emergency department for troponin testing if ACS suspected—send immediately 1