What is the differential diagnosis for a patient with a history of cardiovascular disease presenting with chest pain?

Differential Diagnosis for Chest Pain in Patients with Cardiovascular Disease History

In patients with known cardiovascular disease presenting with chest pain, immediately prioritize life-threatening conditions—acute coronary syndrome, aortic dissection, pulmonary embolism, tension pneumothorax, and esophageal rupture—through rapid ECG acquisition within 10 minutes, focused cardiovascular examination, and immediate cardiac biomarker measurement. 1, 2, 3

Life-Threatening Causes (Must Exclude First)

Acute Coronary Syndrome (ACS)

• Retrosternal pressure, squeezing, or heaviness building gradually over minutes, radiating to left arm, jaw, or neck, associated with diaphoresis, dyspnea, nausea, or syncope. 1, 3
• May occur at rest or with minimal exertion in patients with known cardiovascular disease. 3
• Examination may be completely normal in uncomplicated cases, but look for diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3 gallop, or new mitral regurgitation murmur. 1, 3
• Critical pitfall: Women and elderly patients frequently present with "atypical" symptoms including sharp pain, jaw/neck pain, back pain, epigastric symptoms, or isolated dyspnea without classic chest pressure. 2, 3

Aortic Dissection

• Sudden-onset "ripping" or "tearing" chest or back pain with radiation to upper or lower back. 1, 2, 3
• Examine for pulse differentials between extremities, blood pressure differentials >20 mmHg between arms, or new aortic regurgitation murmur. 1, 3
• Connective tissue disorders (Marfan syndrome), advanced age, severe hypertension, and known aortic disease are high-risk features. 1, 4

Pulmonary Embolism

• Acute dyspnea with pleuritic chest pain; tachycardia present in >90% of patients, accompanied by tachypnea. 1, 2, 3
• Pain typically worsens with inspiration. 1
• Accentuated P2 on cardiac examination may be present. 1

Tension Pneumothorax

• Acute onset chest pain with severe respiratory compromise and unilateral absence of breath sounds. 1, 2, 5

Esophageal Rupture

• History of recent emesis, severe chest pain, subcutaneous emphysema on examination, and potentially painful tympanic abdomen. 1, 2, 5

Serious Non-Immediately Fatal Cardiac Causes

Pericarditis

• Sharp, pleuritic chest pain that worsens when lying supine and improves when leaning forward. 1, 3, 5
• Pain increases with inspiration and coughing. 3, 5
• Listen for friction rub on examination; fever may be present. 1, 3, 5

Myocarditis

• Chest pain accompanied by fever, signs of heart failure, and S3 gallop on examination. 3, 5

Valvular Heart Disease

• Aortic stenosis, aortic regurgitation, and hypertrophic cardiomyopathy produce characteristic murmurs and pulse alterations. 1, 3
• These conditions may precipitate angina by increasing myocardial oxygen demand. 1

Conditions That Precipitate Ischemia in Known Cardiovascular Disease

Increased Myocardial Oxygen Demand

• Hyperthermia with volume contraction, hyperthyroidism, cocaine abuse, sympathomimetic toxicity, severe uncontrolled hypertension. 1

Decreased Myocardial Oxygen Supply

• Anemia, hypoxemia from pulmonary disease, polycythemia, leukemia, thrombocytosis, hypergammaglobulinemia. 1

Common Non-Cardiac Causes

Musculoskeletal

• Costochondritis: Tenderness of costochondral joints on palpation, pain reproducible with chest wall pressure. 2, 3, 5
• Chest wall pain: Localized to very limited area, affected by palpation, breathing, turning, twisting, or bending. 2, 3, 5
• Chest tenderness on palpation or pain with inspiration markedly reduces the probability of ACS. 1

Gastrointestinal

• Gastroesophageal reflux disease (GERD): Burning retrosternal pain related to meals, relieved by antacids. 2, 3
• Esophageal spasm: Can mimic cardiac pain and may respond to nitroglycerin. 2, 3
• Peptic ulcer disease: Epigastric pain that may radiate to back with posterior penetrating ulcers. 2

Pulmonary (Non-PE)

• Pneumonia: Localized pleuritic chest pain with friction rub. 1
• Pneumothorax (non-tension): Pleuritic chest pain with unilateral absence of breath sounds. 1

Algorithmic Approach to Evaluation

Step 1: Immediate Assessment (Within 10 Minutes)

• Obtain 12-lead ECG within 10 minutes of presentation. 1, 2, 3
• If ST-elevation or new ischemic changes present, treat as STEMI immediately and transport by EMS. 3
• Measure cardiac troponin as soon as possible if any suspicion of ACS exists. 1, 2, 3
• Perform focused cardiovascular examination for murmurs, friction rub, S3, pulse differentials, and blood pressure differentials. 1, 5

Step 2: Risk Stratification Based on History

• High-risk features requiring immediate ED transfer by EMS: Age ≥75 years with accompanying dyspnea, syncope, acute delirium, or unexplained fall; hemodynamic instability; diaphoresis; new ECG abnormalities. 2, 3, 5
• Pain characteristics suggesting ACS: Gradual onset over minutes, retrosternal pressure/heaviness/squeezing, radiation to left arm/neck/jaw, precipitation by exertion or emotional stress. 1, 3
• Pain characteristics suggesting non-ischemic etiology: Sharp pain increasing with inspiration, fleeting pain lasting only seconds, pain localized to very small area, pain reproducible with palpation, positional pain. 1, 3

Step 3: Physical Examination Clues

• Pulse or blood pressure differentials between extremities → aortic dissection. 1, 3, 5
• Friction rub → pericarditis. 1, 3, 5
• Chest wall tenderness → musculoskeletal cause (but does not exclude ACS in high-risk patients). 1, 2, 3
• Unilateral absence of breath sounds → pneumothorax or PE. 1, 5

Critical Pitfalls to Avoid

• Never use nitroglycerin response as a diagnostic criterion for myocardial ischemia—esophageal spasm and GERD also respond to nitroglycerin. 2, 3, 5
• Never dismiss chest pain in women, elderly patients, or patients with diabetes based on "atypical" presentation—they frequently present with sharp, stabbing, or positional pain despite having ACS. 2, 3, 5
• Never delay urgent transport to ED by EMS for troponin testing in office settings if ACS or other life-threatening causes are suspected. 2, 3
• Never assume symptoms are noncardiac or psychosomatic until comprehensive cardiac workup is negative. 2
• Never exclude ACS based on age alone—young adults can have ACS, though less common. 2

Special Considerations in Patients with Known Cardiovascular Disease

• Patients with established cardiovascular disease have higher pretest probability of ACS and require lower threshold for aggressive evaluation. 1, 6
• Coexisting conditions may precipitate angina through increased oxygen demand or decreased oxygen supply mechanisms. 1
• History of cerebrovascular or peripheral vascular disease increases risk for acute cardiac events. 1