Pleuritic Chest Pain Characteristics
Pleuritic chest pain feels like sharp, stabbing, or "knifelike" pain that worsens with breathing, coughing, or other respiratory movements. 1
Primary Characteristics
The pain is characteristically sharp and stabbing in quality, distinctly different from the pressure or heaviness typical of cardiac angina. 1 The European Society of Cardiology and American College of Cardiology describe it as having a "knifelike" quality that is localized to a specific area of the chest. 1
The defining feature is that the pain is provoked or intensified by respiratory movements, particularly deep breathing and coughing. 1 This respiratory variation is what distinguishes pleuritic pain from other types of chest discomfort.
How It Differs from Cardiac Pain
The ACC/AHA guidelines specifically list pleuritic pain as a feature not characteristic of myocardial ischemia. 2 Anginal pain from coronary artery disease is typically described as pressure, tightness, or heaviness rather than sharp or stabbing. 1
Important Clinical Caveat
While pleuritic features suggest non-cardiac causes, they do not completely exclude serious cardiac conditions. In the Multicenter Chest Pain Study, acute ischemia was diagnosed in 13% of patients presenting with pain having pleuritic qualities. 2 This is a critical pitfall to avoid—assuming pleuritic pain is always benign.
In Young Individuals at Rest
In young adults presenting with pleuritic chest pain at rest, the differential diagnosis includes:
- Viral pleurisy (among the most common causes) 3, 4
- Pulmonary embolism (found in 5-21% of emergency department presentations with pleuritic pain, even in young patients) 4, 5
- Pneumonia with pleural involvement 1
- Pneumothorax (characterized by sudden onset with dyspnea) 1
- Pericarditis (pain typically increases when lying supine and may improve sitting forward) 1
The most important clinical distinction in young adults is differentiating benign viral pleurisy from pulmonary embolism. 5 Key features suggesting pulmonary embolism include: pleural effusion on chest radiography, history of risk factors for venous thromboembolism, or physical signs of phlebitis. 5
Physical Examination Findings
The pain may be accompanied by a pleural friction rub, which sounds like creaking leather or walking on fresh snow, is biphasic (heard during both inspiration and expiration), and is not affected by coughing. 1