What are the differential diagnoses and initial management steps for a patient presenting with chest pain and shortness of breath?

Differential Diagnoses for Chest Pain and Shortness of Breath

When a patient presents with chest pain and shortness of breath, your immediate priority is to rapidly identify or exclude life-threatening causes: acute coronary syndrome, aortic dissection, pulmonary embolism, tension pneumothorax, pericardial tamponade, and esophageal rupture. 1

Life-Threatening Causes (Must Rule Out First)

Acute Coronary Syndrome (ACS)

• Presentation: Retrosternal pressure, heaviness, or squeezing that builds gradually over minutes (not seconds), radiating to left arm, jaw, or neck, accompanied by diaphoresis, dyspnea, nausea, or syncope 1
• Key feature: Pain occurs at rest or with minimal exertion and lasts longer than fleeting seconds 2, 1
• Critical caveat: Women and elderly patients frequently present with atypical symptoms—primarily dyspnea and nausea rather than classic chest pain 2, 3
• High-risk populations: Age >75 years, diabetes, renal insufficiency, or dementia require immediate attention even with minimal symptoms 1

Aortic Dissection

• Presentation: Sudden-onset "ripping" or "tearing" chest pain radiating to upper or lower back 2, 1
• Physical exam findings: Pulse differentials between extremities, blood pressure differentials >20 mmHg, or new aortic regurgitation murmur 2, 1
• Imaging: CT angiography of chest, abdomen, and pelvis is the diagnostic test of choice 2

Pulmonary Embolism

• Presentation: Acute dyspnea with pleuritic chest pain 1
• Physical findings: Tachycardia present in >90% of patients, tachypnea 1
• Associated features: Presence of risk factors (immobility, recent surgery, malignancy, hypercoagulable state) 1

Tension Pneumothorax

• Presentation: Severe dyspnea with unilateral absence of breath sounds 1
• Physical findings: Tracheal deviation, jugular venous distension, hypotension 1
• ECG changes: May show right axis deviation, diminished R waves, and small-amplitude QRS complexes in precordial leads 4

Pericardial Tamponade

• Presentation: Dyspnea, chest discomfort, hypotension 2
• Diagnostic tool: Transthoracic echocardiography (TTE) is recommended for immediate diagnosis 2, 5

Serious Non-Immediately Fatal Cardiac Causes

Acute Pericarditis

• Presentation: Sharp, pleuritic chest pain that worsens when supine and improves when leaning forward 1, 3
• Physical findings: Friction rub on examination, fever 1
• Key distinguishing feature: Pain increases with inspiration and lying flat 3

Myocarditis

• Presentation: Chest pain with fever, signs of heart failure, S3 gallop 1

Valvular Disease

• Conditions: Aortic stenosis, aortic regurgitation, hypertrophic cardiomyopathy 1
• Assessment: TTE recommended when suspected 2

Common Benign Causes

Costochondritis/Chest Wall Pain

• Presentation: Tenderness of costochondral joints on palpation, pain reproducible with chest wall pressure 1
• Key feature: Localized to very limited area, affected by palpation, breathing, turning, twisting, or bending 1

Gastroesophageal Reflux Disease (GERD)

• Presentation: Burning retrosternal pain related to meals, relieved by antacids 1
• Critical pitfall: Nitroglycerin response should NOT be used as a diagnostic criterion, as esophageal spasm also responds to nitroglycerin 1

Initial Management Algorithm

Immediate Actions (Within 10 Minutes)

Step 1: Obtain 12-lead ECG within 10 minutes 3

• Evaluate for ST-segment changes, new Q waves, T-wave inversions, or new left bundle branch block 3
• Compare with previous ECG if available 3
• Initiate continuous multi-lead ECG monitoring 3

Step 2: Draw high-sensitivity cardiac troponin immediately 2, 3

• High-sensitivity troponins are the preferred standard for establishing biomarker diagnosis of acute MI 2
• Repeat troponin at 10-12 hours after symptom onset for diagnosis and risk assessment 3

Step 3: Obtain focused history 3

• Document exact pain characteristics: nature, onset/duration, location/radiation, precipitating factors, relieving factors, associated symptoms 3
• Assess cardiovascular risk factors: age, diabetes, prior MI, angina history 3

Step 4: Perform targeted physical examination 3

• Evaluate for valvular heart disease, hypertrophic cardiomyopathy, heart failure signs, pulmonary disease 3
• Check for pulse differentials, blood pressure differentials, unilateral breath sounds 2, 1

Step 5: Obtain chest radiograph 3

• Evaluate for pulmonary venous congestion, cardiomegaly, pneumonia, pneumothorax, pleural effusion 3

Step 6: Additional laboratory tests 3

• Hemoglobin to detect anemia as potential contributor 3

Risk Stratification

Use structured risk assessment with evidence-based diagnostic protocols 2

• Low-risk patients: Urgent diagnostic testing for suspected CAD is not needed 2
• Intermediate-risk patients: Will benefit most from cardiac imaging and testing 2
• High-risk features during observation: Recurrent ischemia, elevated troponin, hemodynamic instability require aggressive management 3

Critical Features Distinguishing Ischemic from Non-Ischemic Pain

Favors ACS: 1, 3

• Gradual onset over minutes
• Retrosternal pressure/heaviness/squeezing quality
• Radiation to left arm, neck, jaw
• Precipitation by exertion or emotional stress

Favors non-ischemic etiology: 1

• Sharp pain increasing with inspiration and lying supine
• Fleeting pain lasting only seconds
• Pain localized to very small area
• Pain radiating below umbilicus

Common Pitfalls to Avoid

• Do not dismiss chest pain in women or elderly patients—they frequently present with atypical symptoms 1
• Do not use nitroglycerin response as diagnostic criterion—esophageal spasm also responds to nitroglycerin 1
• Do not assume short duration excludes serious pathology—unstable angina can present with prolonged or recurrent symptoms 3
• Do not routinely order troponin in primary care for suspected ACS—ECG is the only investigation required while arranging urgent referral 6
• Recognize that "atypical" is a misleading descriptor—use "noncardiac" if heart disease is not suspected 2

Disposition Decisions

Immediate transfer to ED by EMS (not personal automobile) if: 1, 3

• Clinical evidence of ACS or other life-threatening causes
• Hemodynamic instability
• High-risk features present

Consider observation unit or admission if: 3

• Intermediate risk with abnormal initial workup
• Recurrent symptoms during observation period
• Elevated troponin levels

Outpatient management acceptable if: 2

• Low risk by structured assessment
• Normal ECG and troponin
• No high-risk features
• Reliable follow-up available