What is the differential diagnosis for chest pain in an adult?

Differential Diagnosis for Chest Pain in Adults

Life-Threatening Causes Requiring Immediate Identification

The initial evaluation must immediately identify or exclude acute coronary syndrome (ACS), aortic dissection, pulmonary embolism, tension pneumothorax, and esophageal rupture—conditions that can rapidly progress to death without urgent intervention. 1

Acute Coronary Syndrome (STEMI/NSTEMI/Unstable Angina)

• Retrosternal pressure, heaviness, or squeezing that builds gradually over minutes (not seconds) and radiates to the left arm, jaw, or neck 1
• Associated with diaphoresis, dyspnea, nausea, or syncope 1
• Physical examination may reveal tachycardia, hypotension, crackles, S3 gallop, or new mitral regurgitation murmur, but examination can be entirely normal in uncomplicated cases 1
• Critical pitfall: Women, elderly patients (>75 years), and those with diabetes frequently present with atypical symptoms including sharp or stabbing pain 2
• ACS accounts for 20% of chest pain in general practice and 45-60% in emergency settings 2

Aortic Dissection

• Sudden-onset "ripping" or "tearing" chest or back pain with maximal intensity at onset 1
• Pulse differential between extremities (present in only 30% of patients, more common in type A than type B) 1
• Blood pressure differential >20 mmHg between arms 1
• New aortic regurgitation murmur (40-75% of type A dissections) 1
• Connective tissue disorders such as Marfan syndrome increase risk 1
• The combination of severe pain, abrupt onset, pulse differential, and widened mediastinum on chest X-ray has >80% probability of dissection 1

Pulmonary Embolism

• Acute dyspnea with pleuritic chest pain 1
• Tachycardia present in >90% of patients 1
• Pain worsens with inspiration 1
• Associated risk factors for thromboembolism should be sought 2

Tension Pneumothorax

• Dyspnea and sharp pain worsening with inspiration 1
• Unilateral absence or marked decrease of breath sounds 1
• Hemodynamic instability in tension physiology 1

Esophageal Rupture

• History of forceful emesis 1
• Subcutaneous emphysema on examination 1
• Pneumothorax present in 20% of patients 1
• Painful, tympanic abdomen may indicate life-threatening gastrointestinal etiology 1

Serious Cardiac Causes (Non-ACS)

Pericarditis

• Sharp, pleuritic chest pain that worsens when lying supine and improves when leaning forward is the hallmark 1, 2
• Pain increases with inspiration and coughing 2
• Pericardial friction rub on auscultation (though may be absent) 1
• Fever commonly present 1
• ECG may show diffuse ST-segment elevation and PR-segment depression 2

Myocarditis

• Chest pain with fever 1
• Signs of heart failure with S3 gallop 1
• Presents similarly to ACS and requires troponin measurement 1

Valvular Disease

• Aortic stenosis: Characteristic systolic murmur with delayed or diminished carotid pulse (pulsus tardus or parvus) 1
• Aortic regurgitation: Diastolic murmur at right sternal border with rapid carotid upstroke 1
• Hypertrophic cardiomyopathy: Increased or displaced left ventricular impulse, prominent a wave in jugular venous pressure, systolic murmur 1

Pulmonary Causes

Pneumonia

• Fever with localized, often pleuritic chest pain 1
• Productive cough 2
• Regional dullness to percussion, egophony, or friction rub 1

Pleuritis

• Sharp chest pain that worsens with deep inspiration 2

Gastrointestinal Causes

Gastrointestinal disorders account for 10-20% of chest pain presentations in outpatient settings 2

Gastroesophageal Reflux Disease (GERD)

• Burning retrosternal pain related to meals or occurring at night 1, 2
• Worsened by stress, often relieved by antacids 2
• Most frequent esophageal cause of chest pain 2

Esophageal Motility Disorders

• Squeezing retrosternal pain or spasm (achalasia, distal esophageal spasm, nutcracker esophagus) 2
• Frequently accompanied by dysphagia 2
• Critical pitfall: Esophageal spasm responds to nitroglycerin, so nitroglycerin relief should NOT be used as a diagnostic criterion for cardiac ischemia 1, 2

Peptic Ulcer Disease

• Epigastric pain that may radiate to the chest 2
• Epigastric tenderness on examination 1

Gallbladder Disease

• Right upper quadrant tenderness with positive Murphy sign 1

Musculoskeletal Causes

Musculoskeletal causes account for 43% of chest pain in general practice when cardiac causes are excluded 2

Costochondritis/Tietze Syndrome

• Tenderness of costochondral joints on palpation 1, 2
• Pain reproducible with chest wall pressure 2
• Pain affected by palpation, breathing, turning, twisting, or bending 1, 2
• Chest tenderness on palpation markedly reduces the probability of ACS 1

Dermatologic Causes

Herpes Zoster

• Pain in dermatomal distribution triggered by touch 1
• Characteristic unilateral rash following dermatome (may appear after pain onset) 1, 2
• Burning, tingling, or stabbing quality affecting skin surface 2

Psychiatric Causes

Psychiatric causes account for 11% of chest pain in general practice and 8% in emergency departments 2

Panic Disorder and Anxiety

• Chest pain with dyspnea, palpitations, and diaphoresis 2
• Often associated with sense of impending doom 2

Critical Algorithmic Approach

Immediate Actions (Within 10 Minutes)

1. Obtain 12-lead ECG within 10 minutes of presentation 1, 2
2. Measure high-sensitivity cardiac troponin immediately if any suspicion of ACS exists 1, 2
3. Perform focused cardiovascular examination checking for pulse differentials, blood pressure differentials between arms, new murmurs, friction rub, and unilateral breath sounds 1

High-Risk Features Mandating Immediate EMS Transport to Emergency Department

• ST-elevation or new ischemic changes on ECG 1, 2
• Hemodynamic instability 1, 2
• Age >75 years with accompanying dyspnea, syncope, acute delirium, or unexplained fall 2
• Associated diaphoresis, dyspnea, nausea, or syncope 2
• Diabetes, renal insufficiency, or known cardiovascular disease 2

Risk Stratification After Initial Evaluation

• If troponin is initially normal, repeat measurement at 3-6 hours to reliably exclude myocardial injury 2
• Pain reproducible with palpation or movement suggests musculoskeletal origin but does not exclude ACS 1, 2
• Sharp, pleuritic pain that is positional makes ACS unlikely but does not exclude it—the Multicenter Chest Pain Study found acute myocardial ischemia in 13% of patients with pleuritic features 2

Common Pitfalls to Avoid

• Never use nitroglycerin response to differentiate cardiac from non-cardiac chest pain—esophageal spasm and other conditions also respond 1, 2
• Never dismiss chest pain in women, elderly patients, or those with diabetes based on atypical presentation 1, 2
• Never assume a normal physical examination excludes ACS—examination can be entirely normal in uncomplicated myocardial infarction 1
• Never delay transfer to the emergency department for office-based troponin testing in patients with suspected ACS 2
• Up to 5% of ACS patients present with a normal initial ECG 2
• Presence of chest wall tenderness does not exclude cardiac disease—up to 15% of myocardial infarctions may coexist with musculoskeletal tenderness 2