What are the differential diagnoses and management for a patient with 1 month of stabbing chest pain?

Differential Diagnoses for 1 Month of Stabbing Chest Pain

For a patient with 1 month of stabbing chest pain, the most likely diagnosis is a musculoskeletal cause such as costochondritis, though you must systematically exclude life-threatening cardiac and non-cardiac conditions before settling on this benign diagnosis. 1

Immediate Life-Threatening Causes to Exclude First

Even with chronic symptoms, you must rule out serious conditions that can present subacutely:

• Acute Coronary Syndrome (unstable angina/NSTEMI) - While typically acute, ACS can present with intermittent symptoms over weeks. Look for retrosternal pressure (not stabbing), radiation to left arm/jaw/neck, precipitation by exertion, and associated diaphoresis or dyspnea. 1 However, the stabbing quality makes this less likely. 2

• Pericarditis - This presents with sharp, pleuritic chest pain that worsens when supine and improves when leaning forward. Listen for a friction rub and check for fever. 1, 3 The stabbing quality and duration fit this diagnosis well.

• Pulmonary embolism - Consider if there's acute dyspnea, pleuritic component, tachycardia, and risk factors (immobility, malignancy, recent surgery). 1 Less likely with 1 month duration unless recurrent.

• Aortic dissection - Would present with sudden "ripping" or "tearing" pain radiating to back, with pulse or blood pressure differentials between extremities. 1, 3 The chronic nature makes this unlikely.

Most Likely Diagnosis: Musculoskeletal Pain

Costochondritis/Tietze syndrome is the most prevalent diagnosis in chest pain presentations, accounting for the majority of cases when cardiac causes are excluded. 2

Key diagnostic features include:

• Tenderness of costochondral joints on palpation 1, 3
• Pain reproducible with chest wall pressure 1
• Pain affected by palpation, breathing, turning, twisting, or bending 2
• Localized to a very limited area 2
• Stabbing quality 1

Other Non-Cardiac Causes to Consider

• Gastroesophageal reflux disease/esophagitis - Burning retrosternal pain related to meals, relieved by antacids, worsening when lying flat. 1, 3 The stabbing quality makes this less typical.

• Pulmonary causes - Pleurisy, pneumonia, or chronic pulmonary conditions can cause chest pain related to breathing movements. 4 Check for cough, fever, or dyspnea.

• Herpes zoster - Pain in dermatomal distribution triggered by touch, with characteristic unilateral rash. 2 May precede rash by days.

Critical Historical Features That Point Away from Cardiac Causes

The following features make cardiac ischemia unlikely:

• Fleeting pain lasting only seconds 1
• Sharp, stabbing quality 1
• Pain localized to a very small area 2, 1
• Pain affected by palpation, breathing, or body position 2
• Pain generated from multiple sites 2

Mandatory Initial Evaluation

Obtain an ECG immediately - Even in the outpatient setting with chronic symptoms, an ECG is mandatory unless a clearly non-cardiac cause is evident. 2 If unavailable in your office, refer to the emergency department. 2

Check cardiac troponin if any concern for ACS - Though less likely with chronic stabbing pain, if the patient has risk factors (age, diabetes, known CAD) or any atypical features, measure high-sensitivity cardiac troponin. 2

Focused physical examination:

• Palpate the chest wall systematically for reproducible tenderness 1, 3
• Listen for friction rub (pericarditis) 1, 3
• Check vital signs for tachycardia, fever, or hemodynamic instability 2
• Assess for pulse or blood pressure differentials 1, 3

High-Risk Features Requiring Immediate Action

Transfer urgently to the emergency department by EMS (not personal automobile) if any of the following are present: 2

• Age >75 years with accompanying dyspnea, syncope, or acute delirium 1
• Hemodynamic instability 1
• Associated diaphoresis, nausea, or syncope 1
• Women, elderly, or diabetic patients with any atypical cardiac symptoms 1, 3
• New ECG abnormalities 2

Critical Pitfalls to Avoid

Do not use nitroglycerin response as a diagnostic test - Esophageal spasm and other non-cardiac conditions also respond to nitroglycerin. 1, 3 This is a common error that leads to misdiagnosis.

Do not dismiss cardiac causes in women, elderly, or diabetic patients - These populations frequently present with atypical symptoms including sharp or positional pain that mimics musculoskeletal causes. 1, 3

Do not delay transfer for troponin testing in the office setting - If ACS is suspected, immediate transfer to the emergency department is required; delayed transfer for diagnostic testing can be detrimental. 2

Management Algorithm

1. Obtain ECG within 10 minutes 2
2. If ECG shows ST elevation or new ischemic changes → Immediate transfer by EMS 2
3. If ECG normal but high-risk features present → Transfer to ED for troponin testing 2
4. If ECG normal and pain reproducible by palpation → Likely costochondritis; manage as outpatient with NSAIDs and reassurance 2
5. If positional (worse supine, better leaning forward) → Consider pericarditis; obtain ECG looking for PR depression and diffuse ST elevation, check inflammatory markers 1, 5