Chest pain differential diagnosis

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

An expert algorithm to assist in the diagnosis of Chest pain can be found here

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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

The frequency of conditions exclusive of acute myocardial infarction in a decreasing order is:^[1]

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.

Differential Diagnosis of Chest Pain:

Differentials on the basis of Etiology	Disease	Clinical manifestations									Diagnosis
		Symptoms								Physical exam	Lab Findings	EKG	Imaging	Gold standard
		Onset	Duration	Type of Pain	Cough	Fever	Dyspnea	Weight loss	Associated Features	Auscultation Findings	Lab Findings	EKG	Imaging	Gold standard
Cardiac	Stable Angina	Sudden (acute)	2-10 minutes	Heaviness/pressure/ tightness/squeezing/ burning (Levine's sign) Retrosternal or left sided chest pain	-	-	+/-	-	Nausea and vomiting Diaphoresis
	Unstable Angina	Acute	10-20 minutes	Same as stable angina but often more severe	-	-	+	-	Nausea and vomiting Diaphoresis Presyncope Palpitations
	Myocardial Infarction	Acute	Commonly > 20 minutes	Same as stable angina but often more severe	-	-	+	-	Nausea and vomiting Diaphoresis Presyncope Palpitations		Elevated cardiac enzymes
	Aortic Stenosis	Acute, recurrent episodes of angina	2-10 minutes	Heaviness/pressure/ tightness/squeezing/ burning (Levine's sign) Retrosternal	-	-	+	-
	Aortic Dissection	Sudden severe progressive pain (common) or chronic (rare)	Variable	Tearing, ripping sensation, knife like	-	-	+	-		Pulse deficit New diastolic murmur Hypotension			CXR: Mediastinal and/or aortic widening CTA MRA TEE
	Pericarditis	Acute or subacute	May last for hours to days	Sharp & localized retrosternal pain	+/-	+	+	-	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 pain	+/-	+	+	-		Kussmaul sign 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	+	-	+	-	Orthopnea Peripheral edema Hemoptysis	S3 Elevated JVP Peripheral edema
	Stress (takotsubo) Cardiomyopathy	Acute	Commonly > 20 minutes	Substernal heaviness or tightness	-	-	+	-	Setting of physical or emotional stress or critical illness		Catecholamines transiently elevated		ST elevation in precordial leads LV regional dysfunction
Pulmonary	Pulmonary Embolism	Acute	May last minutes to hours	Sharp or knifelike or pleuritic pain Localized to side of lesion	+	+/-	+	-	Hemoptysis History of venous thromboembolism or coagulation abnormalities.
	Spontaneous Pneumothorax	Acute	May last minutes to hours	Sharp Localized pleuritic	-	-	+	-		Decreased breath sounds on involved side
	Tension Pneumothorax	Acute	May last minutes to hours	Sharp Pleuritic	-	-	+	-
	Pneumonia	Acute or chronic	Variable	Dull Localized to side of lesion	+	+	+	+/-
	Tracheitis/ Bronchitis	Acute	Variable	Dull Substernal	+	+	+	-
	Pleuritis	Acute or subacute or chronic	May last minutes to hours	Sharp Localized pleuritic	+	+	+	-
	Pulmonary Hypertension	Acute or subacute or chronic	Variable	Substernal pressure like	+	-	+	-	Dyspnea Symptoms of right heart failure (edema)
	Pleural Effusion	Acute or subacute or chronic	Variable	Dull Pleuritic pain	+	+/-	+	+/-
	Asthma & COPD	Acute or subacute or chronic	Variable	Tightness	+	+/-	+	+/-
	Pulmonary Malignancy	Chronic	Week to months	Dull aching	+	+/-	+	+
	Sarcoidosis	Chronic	Days to week	Chest fullness	+	-	+	-
	Acute chest syndrome	Acute	May last minutes to hours	Chest tightness	+/-	+/-	+	-
Gastrointestinal	GERD, Peptic Ulcer	Acute	Minutes to hours (gastroesophageal reflux) Prolonged (peptic ulcer)	Burning Substernal Epigastric	+/-	-	-	+/-	Not specific				Ambulatory reflux monitoring
	Diffuse Esophageal Spasm	Acute	Minutes to hours	Burning Pressure Retrosternal	+	-	-	+/-	Not specific				Esophageal manometry is more than 20% premature contractions
	Esophagitis	Acute	Variable	Burning Epigastric	+	+	-	+/-	Not specific		Elevated IgE Elevated peripherial eosinophils		Endoscopy	Biopsy
	Eosinophilic Esophagitis	Chronic	Variable	Burning Retrosternal Abdominal	+	-	-	-	Alergic diseases Asthma Rinithis Eczema					More than 15 eosinophils per high-power field
	Esophageal Perforation	Acute	Minutes to hours	Burning Upper abdominal	-	+/-	+	-	Eating disorders such as bulimia				Water-soluble contrast esophagram
	Mediastinitis	Acute, Chronic	Variable	Retrosternal irritation	+/-	+	+	-			Postive organisms in sternal culture		CT X-Ray
	Cholelithiasis	Acute, subacute	Minutes to hours	Burning Colicky Right upper abdomen Substernal epigastric	-	+/-	-	-	Obesity Fertile females		LFT's Amylase levels Llipase levels		Transabdominal ultrasound (TAUS) X-ray
	Pancreatitis	Acute, Chronic	Variable	Epigastric Upper left side of the abdomen Pressure like	-	+	+	+/-	Primary cirrhosis Primary sclerosing cholangitis		Amylase levels Lipase levels		CT MRI Transabdominal ultrasound ((TAUS)
	Sliding Hiatal Hernia	Acute	Variable	Epigastric Burning	+	-	+	-	Obstruction Cameron ulcers				Endoscopy Manometry
Musculoskeletal	Costosternal syndromes (costochondritis)	Acute, subacute	Days to weeks	Pressure like on anterior part of chest wall	-	+/-	+	-		Palpation of tender areas			CXR MRI
	Lower rib pain syndromes	Chronic	Variable	Aching Lower chest Upper abdomen	-	-	+	-		Hooking maneuver
	Sternalis syndrome	Chronic	Variable	Pressure like pain Over the body of sternum Sternalis muscle Left or middle side of the chest wall	-	-	-	-	Cardiac diseases				X-ray
	Tietze's syndrome	Acute	Weeks	Pressure like pain over Costosternal joint Sternoclavicular joint Costochondral joint Second and thrid ribs									X-ray MRI	Tests are done to rule out other diseases
	Xiphoidalgia	Acute	Variable	Pressure like pain over Over the xiphoid process Sternum Xiphosternal joint						Provocative test
	Spontaneous sternoclavicular subluxation	Acute, Chronic	Variable	Aching pain over Sternoclavicular joint									CT Esclerosis in X-ray	Esclerosis in X-ray
Rheumatic	Fibromyalgia	Chronic	Variable	Deep ache and burning pain on Shoulders Back of the Neck Chest Lower Back Elbows Hips Shin Knees
	Rheumatoid arthritis	Chronic	Years	Symmetrical joint pain in Wrist Fingers Knees Feet Ankles
	Ankylosing spondylitis	Chronic	Years	Intermittent pain in Spine joint Sacroiliac joint
	Psoriatic arthritis	Chronic	Years	Asymmetrical intermittent pain in Interphalangeal joints Nails Wrist Knees Ankles Lower Back
	Sternocostoclavicular hyperostosis (SAPHO syndrome)	Chronic	Years	Recurrent and multifocal pain in Sternoclavicular joint
	Systemic lupus erythematosus	Chronic	Years
	Relapsing polychondritis	Chronic	Years
Psychiatric	Panic attack/ Disorder
Psychiatric	Other Psychotic disorders
Others	Substance abuse (Cocaine)
	Herpes Zoster
	Sickle cell disease

References

↑ Fruergaard P, Launbjerg J, Hesse B, Jørgensen F, Petri A, Eiken P, Aggestrup S, Elsborg L, Mellemgaard K (1996). "The diagnoses of patients admitted with acute chest pain but without myocardial infarction". European Heart Journal. 17 (7): 1028–34. PMID 8809520. Retrieved 2012-05-02. Unknown parameter |month= ignored (help)

[pmid8809520-1] Fruergaard P, Launbjerg J, Hesse B, Jørgensen F, Petri A, Eiken P, Aggestrup S, Elsborg L, Mellemgaard K (1996). "The diagnoses of patients admitted with acute chest pain but without myocardial infarction". European Heart Journal. 17 (7): 1028–34. PMID 8809520. Retrieved 2012-05-02. Unknown parameter |month= ignored (help)

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