What are the differential diagnoses and initial management steps for a patient presenting with chest pain, considering their age, medical history, and risk factors for cardiac and pulmonary disease?

Differential Diagnoses for Chest Pain

The differential diagnosis for chest pain must prioritize life-threatening conditions first—acute coronary syndrome (ACS), aortic dissection, pulmonary embolism (PE), tension pneumothorax, and esophageal rupture—before considering more benign etiologies, with the initial approach guided by rapid ECG acquisition, focused history emphasizing symptom characteristics and cardiovascular risk factors, and immediate cardiac biomarker measurement. 1

Life-Threatening Causes (Immediate Evaluation Required)

Cardiovascular

• Acute Coronary Syndrome (ACS): Includes STEMI, NSTE-ACS, and unstable angina; presents with retrosternal discomfort building gradually over minutes, often precipitated by physical/emotional stress or occurring at rest, with radiation to left arm, neck, or jaw 1
• Aortic Dissection: Characterized by sudden-onset tearing or ripping chest pain with radiation to the back 1
• Acute Myocardial Infarction: High mortality within 2 hours of symptom onset; requires immediate recognition and intervention 2

Pulmonary

• Pulmonary Embolism (PE): Presents with acute chest pain, typically accompanied by dyspnea; occlusion of pulmonary artery causing severe pain 1, 3, 2
• Tension Pneumothorax: Acute onset chest pain with respiratory compromise 1
• Primary Spontaneous Pneumothorax: Characterized by acute pleuritic chest pain 3

Other Critical Conditions

• Esophageal Rupture: Life-threatening nonvascular syndrome requiring urgent recognition 1

Common Non-Life-Threatening Causes

Pulmonary (Non-Emergent)

• Acute Pleurisy: Intensely painful but prognostically benign; pain related to breathing movements (pleuritic) 3
• Pneumonia: Pain associated with respiratory infection; pleuritic in nature 3
• COPD Exacerbation: Must differentiate from cardiac comorbidity like ACS 3

Gastrointestinal

• Gastroesophageal Reflux Disease (GERD): Epigastric pain that can mimic cardiac symptoms; may respond to nitroglycerin (not diagnostic) 1, 4, 5
• Peptic Ulcer Disease: Epigastric pain; back radiation can occur with posterior penetrating ulcers 5
• Esophageal Spasm: Can respond to nitroglycerin similar to cardiac ischemia 1

Musculoskeletal

• Chest Wall Pain: Reproducible with palpation, worsens with specific movements; positional chest pain usually nonischemic 1, 5
• Costochondritis: Localized tenderness at costochondral junctions 1

Malignant

• Lung Cancer: Constant pain unrelated to respiratory movements 3
• Mesothelioma: Constant pain unrelated to breathing 3
• Pulmonary Hypertension: More constant pain pattern 3

Psychiatric

• Hyperventilation/Panic Disorder: Common in young adults; stress and fear-induced rapid breathing causing chest pain, rarely cardiac in origin 2

Age-Based Differential Considerations

Young Adults (18-44 years)

• Musculoskeletal causes and hyperventilation are more common 1
• ACS less common but cannot be excluded based on age alone 1

Middle Age (45-64 years)

• Increasing prevalence of ACS and coronary artery disease 1
• Balance between cardiac and non-cardiac causes 1

Elderly (≥75 years)

• ACS should be considered when accompanying symptoms include shortness of breath, syncope, acute delirium, or unexplained falls 1, 4
• Age ≥75 years is itself a major risk factor for ACS 4
• Atypical presentations are common; associated symptoms more frequent than classic chest pain 1

Critical Sex-Based Considerations

Women

• Women presenting with chest pain are at significant risk for underdiagnosis, and cardiac causes should always be considered 1, 4, 5
• Women present more commonly with accompanying symptoms: jaw/neck pain, back pain, epigastric symptoms, shortness of breath, nausea, diaphoresis, palpitations 1, 4, 5
• Physician assessments often underestimate risk in women and misclassify their symptoms as noncardiac 4, 5
• What is considered "atypical" is based on male symptom patterns 4

Initial Diagnostic Approach Algorithm

Step 1: Immediate Assessment (Within 10 Minutes)

• Obtain 12-lead ECG within 10 minutes of arrival to assess for STEMI 1, 4
• Perform focused cardiovascular examination to identify complications and assess for aortic dissection, PE, or esophageal rupture 1

Step 2: History Collection

• Obtain focused history including:
  • Nature of pain (pressure, squeezing, tearing, ripping, sharp, stabbing) 1
  • Onset and duration (gradual vs. sudden, minutes vs. hours) 1
  • Location and radiation (retrosternal, left-sided, back, arm, jaw, neck) 1
  • Precipitating factors (exertion, stress, rest, breathing) 1
  • Relieving factors (rest, position, nitroglycerin—though not diagnostic) 1
  • Associated symptoms (dyspnea, nausea, vomiting, diaphoresis, syncope, confusion) 1
  • Cardiovascular risk factor assessment 1

Step 3: Biomarker Testing

• Measure cardiac troponin (cTn) as soon as possible after presentation if ACS suspected 1, 4
• Do not delay transfer to ED for troponin testing if initially evaluated in office setting 1

Step 4: Risk Stratification

• Use clinical decision aids (HEART score, TIMI, GRACE) for undifferentiated chest pain population 6
• Sufficient data for HEART score (History, ECG, Age, Risk factors, Troponin) can be collected efficiently 7

Critical Pitfalls to Avoid

• Do not use nitroglycerin response as diagnostic criterion for myocardial ischemia; other entities like esophageal spasm demonstrate comparable response 1, 4
• Do not assume symptoms are noncardiac based on "atypical" presentation, especially in elderly women 4
• Do not attribute symptoms to anxiety or psychosomatic causes until comprehensive cardiac workup is negative 4
• Do not delay urgent transport to ED by EMS if ACS or other life-threatening causes suspected in office setting 1, 4
• Intensity of symptoms does not correlate with seriousness of disease; there is general similarity of symptoms among different causes 1
• Always consider cardiac comorbidity in COPD exacerbations 3

Setting-Specific Management

Office Setting

• Perform ECG if available; if unavailable, refer patient to ED 1
• Transport urgently to ED by EMS if clinical evidence of ACS or life-threatening causes 1
• Avoid delayed transfer for diagnostic testing 1

Emergency Department

• ECG within 10 minutes for all acute chest pain 1
• Cardiac troponin measurement as soon as possible 1
• Focused cardiovascular examination initially 1