Chest pain differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2]

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Overview

There are several life-threatening causes of chest pain which need to be evaluated for first, which include; myocardial infarction, aortic dissection, esophageal rupture, pulmonary embolism, and tension pneumothorax. The other possible causes of chest pain can be evaluated for by carefully assessing the nature of the pain, and obtaining a thorough patient history.

Differential Diagnosis

5 Life Threatening Diseases to Exclude Immediately

• Aortic dissection
• Esophageal rupture
• Myocardial infarction
• Pulmonary embolism
• Tension pneumothorax

The frequency of conditions exclusive of acute myocardial infarction in a decreasing order is:

• Gastroesophageal disease
• Ischemic heart disease (angina, not myocardial infarction)
• Chest wall syndromes

Differentiating the Life Threatening and Ischemic Causes of Chest Pain from other Disorders

Thorough history including: onset, duration, type of pain, location, exacerbating factors, alleviating factors, and radiation. Risk factors for coronary artery disease: family history, smoking, hyperlipidemia, and diabetes.

Clinical Features of Different Conditions Presenting with Acute Chest Discomfort

CARDIOVASCULAR

Condition	Onset	Duration	Type of pain	Location	Exacerbating factors	Alleviating factors	Radiation	Associated features	Diagnostic findings
Stable Angina	Sudden (acute)	2-10 minutes	Heaviness, pressure, tightness, squeezing, burning (Levine's sign)	Retrosternal or left sided chest pain	Exertion, emotions, cold, stress	Rest, sublingual nitroglycerine (within minutes)	Radiation to neck, jaw, shoulders, or arms (commonly on left)	dyspnea, nausea and vomiting, diaphoresis, presyncope, or palpitations
Unstable Angina	Acute	10-20 minutes	Same as stable angina but often more severe	Retrosternal or left sided chest pain	Same as stable angina but occurs with lower levels of exertion & rest	May or may not relieved by nitroglycerine and rest	Same as stable angina	Same as stable angina
Myocardial Infarction	Acute	Commonly > 20 minutes	Same as stable angina but often more severe	Retrosternal or left sided chest pain	Same as stable angina but occurs with lower levels of exertion & rest	Usually not relieved by nitroglycerine and rest	Same as stable angina	Same as stable angina
Aortic Stenosis	Acute, recurrent episodes of angina	2-10 minutes	Same as stable angina	Retrosternal	Same as stable angina	Same as stable angina	Same as stable angina	Not specific
Aortic Dissection	Sudden severe progressive pain (common) or chronic (rare)	Variable	Tearing, ripping sensation, knife like	Depends on area of dissection	Variable	Unrelenting pain, unrelieved by nitroglycerine and rest	Radiating to back, between shoulder blades (dissection in ascending aorta)	Pulse deficit New diastolic murmur Hypotension	blood pressure (>20 mmHg difference between the right and left arm, CXR: Mediastinal and/or aortic widening
Pericarditis	Acute or subacute	May last for hours to days	Sharp, localized	Retrosternal	Increases with coughing, deep breathing, supine position	Relieved by sitting up and leaning forward	Radiation to shoulder, neck, back abdomen	Pericardial friction rub	EKG changes (typically widespread ST segment elevation)
Pericardial Tamponade	Acute or subacute	May last for hours to days	Sharp and stabbing	Retrosternal	Worsens with deep breathing or coughing	Relieved by sitting upright or leaning forward		Kussmaul sign Peripheral edema Beck triad Pulsus paradoxus	EKG findings: Sinus tachycardia, low QRS voltage, and electrical alternans
Heart Failure	Subacute or chronic	Variable	Dull	Left sided chest pain	Worsens on exertion	Non specific	Non radiating	Dyspnea Orthopnea Peripheral edema Hemoptysis	S3 Elevated JVP
Stress (takotsubo) Cardiomyopathy	Acute	Commonly > 20 minutes	Heaviness, tightness	Substernal	Worsens with stress	No relieving factors	Non radiating	Setting of physical or emotional stress or critical illness Dyspnea	Catecholamines transiently elevated, ST elevation in precordial leads, LV regional dysfunction
Mitral Stenosis

PULMONARY

Condition	Onset	Duration	Type of pain	Location	Exacerbating factors	Alleviating factors	Radiation	Associated features	Diagnostic findings
Pulmonary Embolism	Acute	May last minutes to hours	Sharp, or knifelike pleuritic pain	Localized to side of lesion	Increased on respiratory movements, deep breathing or cough	Not specific	Not specific	Dyspnea, tachypnea, palpitation, and light headedness, hemoptysis, or a history of venous thromboembolism or coagulation abnormalities.
Spontaneous Pneumothorax	Acute	May last minutes to hours	Sharp, localized pleuritic	Localized to side of lesion	Not specific	Not specific	Not specific	Dyspnea, decreased breath sounds on involved side
Tension Pneumothorax
Pneumonia
Tracheitis/ Bronchitis
Pleuritis	Acute, subacute, chronic	May last minutes to hours	Sharp, localized pleuritic	Localized to side of lesion	Increased on respiratory movements, deep breathing or cough	Not specific	Not specific	Dyspnea, cough, fever
Pulmonary Hypertension	Acute, subacute, chronic	Variable	Pressure like	Substernal	Not specific	Not specific	Not specific	Dyspnea, symptoms of right heart failure (edema
Pleural Effusion
Asthma & COPD
Pulmonary Malignancy
Sarcoidosis
Acute chest syndrome

GASTROINTESTINAL

Condition	Onset	Duration	Type of pain	Location	Exacerbating factors	Alleviating factors	Radiation	Associated features	Diagnostic findings
GERD, Peptic Ulcer	Acute	Minutes to hours (gastroesophageal reflux), prolonged (peptic ulcer)	Burning	Substernal, epigastric	Increases on alcohol, aspirin, post meal lying down, morning, empty stomach	Relieves on antacid, food	Not specific	Not specific
Esophageal Spasm	Acute	Minutes to hours	Burning, pressure	Retrosternal	Not specific	Relieved by sublingual nitroglycerine	Not specific	Not specific (closely mimic angina)
Esophagitis
Eosinophilic Esophagitis
Esophageal Perforation
Mediastinitis
Cholelithiasis	Acute, subacute	Minutes to hours	Burning, colicky	Right upper abdomen, substernal, epigastric	Increases post meal, fatty food, 1-2 hours post meal	Analgesics	Not specific	Not specific
Pancreatitis
Sliding Hiatal Hernia

MUSCULOSKELETAL

Condition	Onset	Duration	Type of pain	Location	Exacerbating factors	Alleviating factors	Radiation	Associated features	Diagnostic findings
Musculo-skeletal Pain	Acute, subacute	Variable	Pressure, aching	Localized to involved area	Increases by movement and pressure on involved area	Analgesics	Not specific	Not specific
Rib pain
Isolated musculoskeletal chest pain syndromes
Rheumatic diseases
Traumatic

PSYCHIATRIC

Condition	Onset	Duration	Type of pain	Location	Exacerbating factors	Alleviating factors	Radiation	Associated features	Diagnostic findings
Panic attack/ Disorder
Other Psychotic disorders	Acute, subacute, chronic	Variable	Variable	Variable	Variable	Not specific	Not specific	History of depression, Panic attacks, Agrophobia

OTHER

Condition	Onset	Duration	Type of pain	Location	Exacerbating factors	Alleviating factors	Radiation	Associated features	Diagnostic findings
Substance abuse (Cocaine)
Referred pain
Herpes Zoster
Domestic abuse
Stress fracture
Sickle cell disease

Isolated musculoskeletal chest pain syndromes:

Condition	Onset	Duration	Type of pain	Location	Exacerbating factors	Alleviating factors	Radiation	Associated features	Diagnostic findings
Costosternal syndromes (costochondritis)
Lower rib pain syndromes
Sternalis syndrome
Tietze's syndrome
Xiphoidalgia
Spontaneous sternoclavicular subluxation
Posterior chest wall pain syndromes

Rheumatic diseases:

Condition	Onset	Duration	Type of pain	Location	Exacerbating factors	Alleviating factors	Radiation	Associated features	Diagnostic findings
Fibromyalgia
Rheumatoid arthritis
Ankylosing spondylitis
Psoriatic arthritis
Sternocostoclavicular hyperostosis (SAPHO syndrome)
Systemic lupus erythematosus
Relapsing polychondritis