What is the differential diagnosis of chest pain?

Differential Diagnosis of Chest Pain

Immediate Life-Threatening Causes (Must Rule Out First)

The initial evaluation of chest pain must prioritize identification of life-threatening conditions that require emergent intervention: acute coronary syndrome (ACS), pulmonary embolism (PE), aortic dissection, and esophageal rupture. 1

Acute Coronary Syndrome

• Presents with deep, substernal pressure, heaviness, squeezing, or tightness that builds gradually over minutes 2
• Pain is characteristically diffuse and difficult to localize, not point-specific 2
• Radiation to left arm, jaw, or neck increases likelihood of myocardial ischemia 2
• Associated findings: diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3 gallop, mitral regurgitation murmur 1
• Critical pitfall: Examination may be completely normal in uncomplicated cases 1
• ECG must be obtained and interpreted within 10 minutes of arrival to identify STEMI 1
• Cardiac troponin should be measured as soon as possible after presentation 1

Pulmonary Embolism

• Acute pleuritic chest pain with dyspnea and tachycardia present in >90% of patients 1, 3
• Pain worsens with inspiration 1
• Tachycardia and dyspnea are the dominant features 1

Aortic Dissection

• Sudden-onset "ripping" or "tearing" chest pain radiating to the back 1, 2, 3
• Extremity pulse differential present in 30% of patients (more common in Type A than Type B) 1
• Combination of severe pain, abrupt onset, pulse differential, and widened mediastinum on chest X-ray yields >80% probability of dissection 1
• Syncope occurs in >10% of cases 1
• Aortic regurgitation present in 40-75% of Type A dissections 1

Esophageal Rupture

• History of emesis preceding chest pain 1
• Subcutaneous emphysema on examination 1
• Pneumothorax occurs in 20% of patients 1
• Unilateral decreased or absent breath sounds 1
• Painful, tympanic abdomen may be present 1

Noncoronary Cardiac Causes

Valvular Heart Disease

• Aortic stenosis: Characteristic systolic murmur with tardus or parvus carotid pulse 1
• Aortic regurgitation: Diastolic murmur at right of sternum with rapid carotid upstroke 1
• Hypertrophic cardiomyopathy: Increased or displaced left ventricular impulse, prominent a wave in jugular venous pressure, systolic murmur 1

Pericarditis

• Sharp, pleuritic chest pain that increases in supine position and improves when sitting forward 1, 3
• Friction rub may be audible 1
• Fever commonly present 1
• ECG shows widespread ST-elevation with PR depression 3

Myocarditis

• Fever with chest pain 1
• Heart failure signs including S3 gallop 1

Stress Cardiomyopathy

• Presents in a similar manner as ACS 1

Pulmonary Causes

Pneumonia

• Fever with localized chest pain, may be pleuritic 1, 3
• Friction rub may be present 1
• Regional dullness to percussion and egophony 1, 3

Pneumothorax

• Dyspnea and pain worsening with inspiration 1, 3
• Unilateral absence of breath sounds 1, 3
• Hyperresonant percussion 3

Gastrointestinal Causes

Gastroesophageal Reflux Disease/Esophagitis

• Squeezing or burning chest pain 1
• Duration can be minutes to hours 1
• Often occurs after meals or at night 1
• May worsen with stress 1
• Epigastric tenderness on examination 1
• Critical pitfall: Can mimic myocardial ischemia and may respond to nitroglycerin, making nitroglycerin response an unreliable diagnostic criterion 2, 4, 3

Peptic Ulcer Disease

• Epigastric tenderness 1

Gallbladder Disease

• Right upper quadrant tenderness with Murphy sign 1

Musculoskeletal Causes

Costochondritis/Tietze Syndrome

• Tenderness of costochondral joints on palpation 1, 3
• Critical pitfall: 7% of patients with reproducible chest wall tenderness still have ACS—do not assume palpable tenderness excludes serious pathology 3

Muscle Strain

• Most common noncardiac cause of chest pain 1
• Pain reproducible with movement or palpation 1

Dermatologic Causes

Herpes Zoster

• Pain in dermatomal distribution, triggered by touch 1, 3
• Characteristic unilateral dermatomal rash 1, 3

Pain Characteristics That Decrease Likelihood of Life-Threatening Cardiac Causes

• Sharp, fleeting pain lasting only seconds 2, 4
• Pain related to inspiration or position changes 2, 4
• Pain shifting locations 2
• Point tenderness reproducible by palpation (though does not exclude ACS) 2, 3

Recommended Diagnostic Approach

For any patient with acute chest pain, obtain ECG within 10 minutes and measure cardiac troponin as soon as possible 1, 4, 3

• Perform focused cardiovascular examination to identify complications and serious causes 1
• Obtain chest radiograph to evaluate for pneumothorax, pneumonia, pleural effusion, or widened mediastinum 3
• Patients with suspected ACS initially evaluated in office setting should be transported urgently to ED by EMS—delayed transfer for troponin testing should be avoided 1, 3
• If acute myocardial injury is ruled out and symptoms persist, evaluate for noncardiac causes 1
• For recurrent chest pain without cardiac or pulmonary cause, evaluation for gastrointestinal causes is reasonable 1

Critical Pitfalls to Avoid

• Never dismiss chest pain based on age or sex alone—women and elderly patients frequently present with atypical pain qualities, including isolated dyspnea, nausea, or fatigue without classic substernal pressure 2
• Sharp, pleuritic pain does not exclude cardiac causes—pericarditis presents with sharp pain, and atypical ACS presentations occur 2, 3
• Never use nitroglycerin response as a diagnostic criterion—esophageal spasm and other noncardiac conditions also respond to nitroglycerin 2, 4, 3
• Examination may be completely normal in uncomplicated ACS 1
• Reproducible chest wall tenderness does not exclude ACS—7% of patients with palpable tenderness have acute coronary syndrome 3