Differential Diagnosis for Chest Pain
The patient's symptoms of chest pain at rest that lasts for 30 minutes and then eases with GTN (glyceryl trinitrate) spray can be analyzed through the following differential diagnosis categories:
Single Most Likely Diagnosis
- Unstable Angina: This is the most likely diagnosis given the patient's symptoms. Unstable angina is characterized by chest pain or discomfort that occurs at rest or with minimal exertion, lasts more than 20 minutes, and may be relieved by GTN. The fact that the pain eases with GTN spray supports this diagnosis, as GTN is a nitrate that helps relax blood vessels, improving blood flow to the heart.
Other Likely Diagnoses
- Stable Angina: Although less likely than unstable angina due to the pain occurring at rest, stable angina could be considered if the patient has a history of angina and the pain pattern has recently changed. However, stable angina typically occurs with exertion and is relieved by rest.
- Acute Coronary Syndrome (ACS) without ST-Elevation: This could include non-ST elevation myocardial infarction (NSTEMI), which presents with symptoms similar to unstable angina but with evidence of myocardial damage on biomarkers like troponin.
Do Not Miss Diagnoses
- Myocardial Infarction (MI): Especially ST-Elevation Myocardial Infarction (STEMI), which is a medical emergency. Although the pain easing with GTN might suggest unstable angina, any chest pain at rest could potentially be an MI, and missing this diagnosis could be fatal.
- Aortic Dissection: This is a life-threatening condition where there is a tear in the aorta's inner layer. It can cause severe, tearing chest pain that may radiate to the back. Although the pain pattern and response to GTN do not typically suggest aortic dissection, it's crucial not to miss this diagnosis due to its high mortality rate.
- Pulmonary Embolism (PE): While less common, PE can cause chest pain that worsens with deep breathing and may not respond to GTN. It's essential to consider PE, especially if there are risk factors such as recent travel, immobilization, or family history of clotting disorders.
Rare Diagnoses
- Pericarditis: Inflammation of the pericardium, the sac surrounding the heart, can cause chest pain that may improve with leaning forward and worsen with lying down. The response to GTN is not typical for pericarditis, making this a less likely diagnosis.
- Esophageal Spasm or Esophagitis: These conditions can cause chest pain that may mimic cardiac pain but typically do not respond to GTN. They are less likely given the specific response to GTN spray.