What are the differential diagnoses for a 70‑year‑old patient with sudden onset chest pain that is tender over the entire sternum and has persisted for three days?

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Differential Diagnosis for 70-Year-Old with Sudden Onset Chest Pain and Bilateral Sternal Tenderness Lasting 3 Days

The most likely diagnosis is costochondritis, but you must immediately exclude acute coronary syndrome, pulmonary embolism, and pericarditis before making this diagnosis—bilateral sternal tenderness does NOT rule out life-threatening cardiac disease. 1

Immediate Life-Threatening Causes Requiring Urgent Exclusion

Acute Coronary Syndrome (ACS)

  • Obtain a 12-lead ECG within 10 minutes to identify ST-elevation, ST-depression, T-wave inversions, or new ischemic changes. 2, 1
  • Measure high-sensitivity cardiac troponin immediately and repeat at 3–6 hours; a single normal troponin does not exclude ACS. 2, 1
  • Approximately 13% of patients with sharp or pleuritic-type chest pain still have acute myocardial ischemia, so the quality of pain does not exclude ACS. 1
  • A completely normal physical examination does not exclude uncomplicated myocardial infarction; up to 30–40% of acute MIs present with normal findings. 1, 3
  • Age 70 years is a high-risk feature; elderly patients frequently present with atypical symptoms including sharp, stabbing, or positional pain. 1
  • Up to 7% of patients with reproducible chest-wall tenderness still have ACS, so palpable tenderness does not rule out cardiac disease. 1

Pulmonary Embolism

  • Sudden onset of chest pain with tachycardia (present in >90% of PE patients) and dyspnea suggests PE. 1
  • Measure vital signs including oxygen saturation and assess for tachypnea (>20 breaths/min occurs in ~70% of PE). 1
  • Three-day duration does not exclude PE; chronic thromboembolic disease may present with days to weeks of symptoms. 1

Aortic Dissection

  • Sudden "ripping" or "tearing" chest pain maximal at onset radiating to the back is characteristic. 1
  • Measure blood pressure in both arms; a systolic difference >20 mm Hg suggests dissection. 1, 3
  • Listen for a new aortic regurgitation murmur (present in 40–75% of type A dissections). 1

Pericarditis

  • Sharp, pleuritic chest pain that worsens when lying supine and improves when leaning forward is the hallmark. 1
  • Listen for a pericardial friction rub (though absence does not exclude disease). 1
  • Fever commonly accompanies pericarditis. 1
  • ECG may show diffuse ST-elevation with PR-depression. 1

Serious Non-Immediately Fatal Causes

Myocarditis

  • Chest pain with fever and signs of heart failure (S3 gallop) can mimic ACS. 1
  • Troponin measurement is required to differentiate from ACS. 1

Pneumonia

  • Fever with localized pleuritic chest pain, productive cough, and egophony on examination. 1
  • Chest radiography is diagnostic. 1

Most Likely Diagnosis After Cardiac Exclusion

Costochondritis/Tietze Syndrome

  • Accounts for approximately 43% of chest pain presentations in primary care after cardiac causes are excluded. 1
  • Bilateral tenderness of costochondral joints on palpation is the key diagnostic finding. 1
  • Pain is reproducible with chest wall pressure and affected by breathing, turning, twisting, or bending. 1
  • Three-day duration without progression or crescendo pattern makes unstable angina unlikely. 1

Gastroesophageal Reflux Disease (GERD)

  • Burning retrosternal pain related to meals or occurring at night, often relieved by antacids. 1
  • Do not rely on nitroglycerin response to differentiate cardiac from esophageal pain, as esophageal spasm also responds. 1

Algorithmic Management Pathway

  1. First 10 minutes: Obtain 12-lead ECG and measure high-sensitivity troponin. 1

  2. If ECG shows ST-elevation or new ischemic changes OR troponin is elevated: Activate emergency medical services immediately and transport to emergency department. 1

  3. If ECG and initial troponin are normal: Repeat troponin at 3–6 hours. 1

  4. Perform focused cardiovascular examination: Assess for diaphoresis, tachycardia, hypotension, pulmonary crackles, S3 gallop, new murmurs, pericardial friction rub, and unilateral breath sounds. 1

  5. Palpate costochondral junctions bilaterally: If tenderness is reproducible and pain worsens with chest wall movement, costochondritis is likely. 1

  6. If both troponins are normal and pain is reproducible with palpation: Diagnose costochondritis and prescribe NSAIDs (ibuprofen 600–800 mg three times daily for 1–2 weeks). 1

  7. Arrange outpatient stress testing or coronary CT angiography within 72 hours given the patient's age (70 years) and cardiovascular risk profile, even if initial work-up is negative. 1

Critical Pitfalls to Avoid

  • Do not dismiss ACS based solely on reproducible chest-wall tenderness; up to 7% of such patients still have acute coronary syndrome. 1
  • Do not assume a normal physical examination excludes myocardial infarction; uncomplicated MI can present with entirely normal findings. 1
  • Do not rely on nitroglycerin response to differentiate cardiac from non-cardiac chest pain, as esophageal spasm and other conditions also respond. 1
  • Do not delay transfer to the emergency department for troponin testing in office settings when clinical suspicion for ACS exists; transport urgently by EMS. 1
  • Do not dismiss cardiac causes in elderly patients based on atypical presentations; they frequently present with sharp, stabbing, or positional pain. 1

References

1
Guideline

Differential Diagnosis for Chest Pain

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

3
Guideline

Acute Chest Pain Evaluation in Women – Immediate Diagnostic and Management Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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