Differential Diagnosis and Management Approach
Most Likely Diagnosis: Musculoskeletal Chest Pain (Costochondritis)
Based on the clinical presentation—mid-sternal pain radiating to neck/throat and costovertebral areas, pain relief with manual compression, absence of cardiac changes on EKG, and lack of gastrointestinal symptoms—this is most consistent with musculoskeletal chest wall pain, specifically costochondritis. 1
Key Diagnostic Features Supporting Musculoskeletal Etiology
- Pain reproducible with palpation/compression is the hallmark of chest wall pain and effectively rules out acute coronary syndrome 1, 2
- Normal EKG significantly reduces likelihood of cardiac ischemia, though does not completely exclude it 1
- Absence of dyspnea, fever, or constitutional symptoms makes serious pulmonary causes (pneumonia, pulmonary embolism, pneumothorax) unlikely 1
- No gastrointestinal symptoms (no nausea, vomiting, dysphagia, or meal-related patterns) makes esophageal/gastric causes less probable 1
Critical Red Flags to Exclude (None Present in This Case)
The 2021 AHA/ACC/CHEST guidelines emphasize that certain features mandate urgent cardiac or other serious evaluation 1:
- Cardiac red flags (ABSENT): No ST-segment changes, no troponin elevation expected given normal EKG and symptom pattern, no radiation to left arm/jaw typical of angina 1
- Pulmonary red flags (ABSENT): No dyspnea, no pleuritic component worsening with inspiration 1
- Gastrointestinal alarm symptoms (ABSENT): No dysphagia, odynophagia, GI bleeding, weight loss, or recurrent vomiting that would warrant urgent endoscopy 1
Recommended Management Algorithm
Immediate Actions
Serial troponin measurement should still be obtained despite low suspicion, as the 2021 AHA/ACC guidelines recommend troponin measurement in all patients with acute chest pain to definitively exclude myocardial injury 1
Chest radiograph is reasonable to exclude pneumonia, pneumothorax, or other thoracic pathology given the costovertebral radiation pattern 1
If Cardiac Workup Negative (Expected)
Trial of NSAIDs for costochondritis is the appropriate first-line treatment 2:
- Ibuprofen 400-600mg three times daily with food
- Expected improvement within 48-72 hours
- Pain relief with compression supports this diagnosis
Follow-up Considerations
If symptoms persist beyond 2 weeks despite NSAIDs, the 2021 AHA/ACC guidelines recommend evaluation for alternative noncardiac causes 1:
- Gastrointestinal evaluation: Consider trial of empiric acid suppression therapy (proton pump inhibitor) for 2-4 weeks, as gastroesophageal reflux can present with atypical mid-sternal pain radiating to throat 1
- Upper endoscopy only if alarm symptoms develop (dysphagia, weight loss, GI bleeding) or if empiric PPI trial fails 1
Important Clinical Pitfalls to Avoid
- Do not dismiss cardiac causes in women: The 2021 guidelines emphasize that women are at risk for underdiagnosis of ACS and may present with atypical symptoms 1
- However, pain reproducible with palpation has high negative predictive value for excluding ACS 2
- Avoid delayed transfer for troponin testing: If initially evaluated in office setting, patient should be sent to ED for troponin measurement rather than delaying 1
- Do not use nitroglycerin response as diagnostic criterion: Relief with nitroglycerin is not specific for cardiac ischemia, as esophageal spasm responds similarly 1
Prognosis
Musculoskeletal chest pain is benign with excellent prognosis and typically resolves with conservative management within days to weeks 1, 2. The absence of cardiac risk factors, normal EKG, and characteristic pain relief with compression strongly support this favorable outcome.