What is the differential diagnosis for a 55-year-old patient presenting with cough, leg edema, shortness of breath, and chest pain?

Differential Diagnosis for a 55-Year-Old Patient with Cough, Leg Edema, Shortness of Breath, and Chest Pain

The most critical diagnoses to consider immediately are acute heart failure (particularly heart failure with preserved ejection fraction), acute coronary syndrome, and pulmonary embolism, as these represent life-threatening conditions requiring urgent intervention. 1, 2

Life-Threatening Diagnoses (Rule Out First)

Acute Coronary Syndrome

• Chest pain with shortness of breath in a 55-year-old warrants immediate consideration of ACS, even when accompanied by other symptoms like leg edema 1
• The combination of chest discomfort and dyspnea is a classic presentation, particularly in this age group where cardiovascular risk increases significantly 1
• Women and some patients may present with "atypical" symptoms including shortness of breath as the predominant feature rather than classic chest pain 1

Acute Heart Failure

• The triad of dyspnea, leg edema, and chest pain strongly suggests acute decompensated heart failure, particularly left-heart backward failure or biventricular failure 1, 2
• Heart failure with preserved ejection fraction (HFpEF) typically presents with dyspnea, fatigue, and bilateral ankle edema, often in patients with hypertension and obesity 2
• Left-heart backward failure manifests with shortness of breath, dry cough (sometimes with frothy sputum), and fine rales on lung examination 1
• Bilateral leg edema indicates systemic venous congestion, suggesting right-sided involvement or biventricular failure 1, 3

Pulmonary Embolism

• PE must be excluded in any patient presenting with acute dyspnea, chest pain, and leg edema (which may indicate deep vein thrombosis as the source) 1
• The combination of pleuritic chest pain, dyspnea, and unilateral or bilateral leg swelling raises suspicion for thromboembolic disease 1, 4
• Tachycardia (heart rate >100 bpm) would further support this diagnosis 5

Pulmonary Causes

Pneumonia

• Fever ≥38°C (100.4°F) and tachycardia are specific findings suggesting pneumonia in a patient with cough and dyspnea 5
• Chest pain in pneumonia is typically pleuritic in nature, worsening with breathing 4
• The presence of cough makes infectious etiologies important to consider, though bilateral leg edema would be unusual for isolated pneumonia 1, 5

COVID-19 Pneumonia

• COVID-19 should be considered given the constellation of fever, cough, dry cough, and shortness of breath 1
• Post-acute sequelae of SARS-CoV-2 (PASC) can present with persistent dyspnea and chest pain even after acute infection 1
• Chest imaging typically shows bilateral ground-glass opacities or consolidations 1

Pleural Disease

• Pleurisy presents with intensely painful, breathing-related chest pain along with cough and dyspnea 4
• Bilateral pleural effusions can cause dyspnea and may be associated with underlying cardiac or systemic disease 6

Chronic Conditions Presenting Acutely

Chronic Obstructive Pulmonary Disease (COPD)

• Chronic dyspnea with acute exacerbation can present with worsening shortness of breath, cough, and chest discomfort 1
• Important to differentiate from concurrent ACS, as cardiac comorbidity is common in COPD patients 4

Pulmonary Hypertension

• Can present with dyspnea, chest pain (more constant, unrelated to breathing), and signs of right heart failure including leg edema 1, 4

Systemic Causes of Bilateral Leg Edema

Non-Cardiac Causes

• Liver disease, malnutrition, thyroid disorder, and renal disease can all cause bilateral leg edema with associated dyspnea 3
• Pelvic tumors causing venous obstruction should be considered, particularly if edema is progressive 3
• Medication-induced edema (calcium channel blockers, NSAIDs) is common in this age group 3

Critical Pitfalls to Avoid

• Do not dismiss chest pain as "atypical" based solely on the presence of other symptoms—ACS remains a priority diagnosis 1
• Do not attribute all symptoms to a single diagnosis prematurely—more than 30% of chronic dyspnea cases are multifactorial 1
• In patients >55 years with orthopnea and leg edema, cardiac failure must be strongly considered even if other symptoms suggest pulmonary disease 5, 2
• Always assess for signs of respiratory distress including increased respiratory rate, breathlessness, intercostal retractions, or altered consciousness, which indicate severity 5

Immediate Diagnostic Approach

The initial workup should include:

• ECG to evaluate for acute ischemia or arrhythmia 1
• Chest X-ray to assess for pulmonary edema, consolidation, or pleural effusions 1
• Cardiac biomarkers (troponin, BNP/NT-proBNP) to evaluate for ACS and heart failure 1, 2
• D-dimer if PE is suspected based on clinical probability 1
• Complete blood count and inflammatory markers to assess for infection 5
• Oxygen saturation and arterial blood gas if respiratory distress is present 5