What is the differential diagnosis for acute chest pain in an adult patient with no prior medical history?

Differential Diagnosis for Acute Chest Pain

The differential diagnosis for acute chest pain must prioritize immediate exclusion of life-threatening conditions—acute coronary syndrome, pulmonary embolism, aortic dissection, pneumothorax, and pericarditis—before considering more benign etiologies. 1

Life-Threatening Causes (Must Exclude First)

Cardiac Causes

• Acute Coronary Syndrome/Myocardial Infarction: Prolonged chest discomfort with radiation to jaw, neck, or left arm; associated with nausea, diaphoresis, and dyspnea; age and male gender increase likelihood 1, 2
• Unstable Angina: Chest pain at rest or with minimal exertion, new-onset severe angina, or crescendo pattern of previously stable angina 2
• Acute Pericarditis: Sharp, pleuritic pain that improves when sitting forward and worsens supine; widespread ST-elevation with PR depression on ECG; pericardial friction rub may be audible 1, 3
• Myocarditis: Fever, chest pain, signs of heart failure, and S3 gallop 3

Vascular Causes

• Aortic Dissection: Sudden-onset "ripping" or "tearing" chest pain radiating to the back; pulse differential between upper extremities in 30% of cases 3, 4
• Pulmonary Embolism: Dyspnea, pleuritic chest pain, tachycardia (>90% of cases), and tachypnea; may have unilateral leg swelling or recent immobilization 5, 3

Pulmonary Causes

• Tension Pneumothorax: Classic triad of dyspnea, pleuritic pain on inspiration, and unilateral absence of breath sounds with hyperresonant percussion; tracheal deviation and hemodynamic instability in severe cases 3, 4
• Pneumonia: Localized pleuritic pain, fever, productive cough, regional dullness to percussion, egophony, and possible pleural friction rub 3, 2

Common Non-Life-Threatening Causes

Musculoskeletal

• Costochondritis/Chest Wall Syndrome: Tenderness of costochondral joints reproducible on palpation; however, 7% of patients with reproducible chest wall pain may still have acute coronary syndrome, so this finding does not exclude cardiac disease 3, 2
• Musculoskeletal pain: Most prevalent diagnosis in primary care, accounting for the majority of chest pain presentations 1, 6

Gastrointestinal

• Gastroesophageal Reflux Disease (GERD): Burning retrosternal pain, acid regurgitation, sour or bitter taste in mouth; pain may be postprandial 1, 2
• Esophageal spasm or dysmotility: Can mimic cardiac pain; may respond to nitroglycerin (though this does not confirm or exclude cardiac etiology) 1, 3
• Esophageal perforation: Severe chest pain after vomiting or instrumentation; surgical emergency 4

Psychological

• Panic Disorder/Anxiety: Recurrent episodes with trembling, dizziness, paresthesias, chills or hot flushes; diagnosis of exclusion after negative cardiac workup 1, 2

Other Pulmonary

• Pleural effusion: May develop in 46% of pulmonary embolism cases; causes ongoing pleuritic discomfort 3
• Pleuritis: Sharp, pleuritic pain; pleural friction rub (biphasic sound) indicates pleural inflammation 3

Other Causes

• Herpes Zoster: Pain in dermatomal distribution triggered by touch; characteristic unilateral dermatomal rash 3
• Valvular Heart Disease: May present with chest pain; requires echocardiographic evaluation 1

Special Populations

Sickle Cell Disease

• Acute Chest Syndrome: Patients with sickle cell disease reporting acute chest pain require emergency transfer to acute care setting; acute coronary syndrome must be excluded 1

Post-CABG Patients

• Graft stenosis or occlusion: 10-20% of saphenous vein grafts fail within one year; internal mammary artery grafts have 90-95% patency at 10-15 years 1
• Post-sternotomy pain syndrome: Discomfort persisting ≥2 months after thoracic surgery without apparent cause; incidence 7-66% 1
• Pericarditis, sternal wound infection, or nonunion: Must be considered in post-operative period 1

Critical Diagnostic Approach

The 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guidelines emphasize that patients with acute chest pain should be evaluated for noncardiac causes only after persistent or recurring symptoms despite negative stress test or anatomic cardiac evaluation, or low-risk designation by a clinical decision pathway. 1

Initial Mandatory Testing

• 12-lead ECG within 10 minutes of presentation to identify STEMI, new left bundle branch block, Q waves, T wave inversions, or pericarditis patterns 5, 3, 2
• Cardiac troponin immediately upon presentation, even if pleuritic characteristics make ischemia less likely; serial measurements at 3-6 hours if initial negative but symptoms persist 5, 7
• Chest radiography for pneumothorax, pneumonia, pleural effusion, or widened mediastinum 3, 2

Risk Stratification Tools

• Wells score or Geneva score for pulmonary embolism pretest probability 5
• D-dimer with age-adjusted cutoffs if low-to-intermediate probability of pulmonary embolism 5
• CT pulmonary angiogram if D-dimer elevated or high clinical probability of pulmonary embolism 5

Critical Pitfalls to Avoid

• Do not assume reproducible chest wall tenderness excludes serious pathology: 7% of patients with palpable tenderness have acute coronary syndrome 3
• Nitroglycerin response is not diagnostic: Relief with nitroglycerin does not confirm or exclude myocardial ischemia 3
• Sharp, pleuritic pain does not exclude cardiac ischemia: While it makes ischemic heart disease less likely, it does not completely rule it out 3
• Women and elderly patients require heightened vigilance: They more frequently present with atypical symptoms 5, 7
• A single normal ECG does not rule out cardiac causes if symptoms persist; serial ECGs are necessary 7
• Chest X-ray has limited sensitivity: Normal in 11-62% of certain conditions like diaphragmatic injuries 3