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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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

• 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.

Differential Diagnosis of Chest Pain:

Differentials on the basis of Etiology	Disease	Clinical manifestations									Diagnosis
		Symptoms								Physical exam	Lab Findings			Gold standard
		Onset	Duration	Type of Pain	Cough	Fever	Dyspnea	Weight loss	Associated Features	Auscultation Findings		EKG	Imaging
Cardiac	Stable Angina	Sudden (acute)	2-10 minutes	Heaviness/pressure/ tightness/squeezing/ burning (Levine's sign) Retrosternal or left sided chest pain	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 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	Radiation to neck, jaw, shoulders, or arms (commonly on left)	Dyspnea Nausea and vomiting Diaphoresis Presyncope Palpitations
	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	Radiation to neck, jaw, shoulders, or arms (commonly on left)	Dyspnea Nausea and vomiting Diaphoresis Presyncope Palpitations
	Aortic Stenosis	Acute, recurrent episodes of angina	2-10 minutes	Heaviness/pressure/ tightness/squeezing/ burning (Levine's sign) Retrosternal	Retrosternal	Exertion Emotions Cold Stress	Rest Sublingual nitroglycerine (within minutes)	Radiation to neck, jaw, shoulders, or arms (commonly on left)
	Aortic Dissection	Sudden severe progressive pain (common) or chronic (rare)	Variable	Tearing, ripping sensation, knife like	Depends on area of dissection	Variable	No relieving factors	Radiating to back, between shoulder blades (dissection in ascending aorta)	Pulse deficit New diastolic murmur Hypotension
	Pericarditis	Acute or subacute	May last for hours to days	Sharp & localized retrosternal pain	Retrosternal	Increases with coughing, deep breathing, supine position	Relieved by sitting up and leaning forward	Radiation to shoulder, neck, back abdomen	Pericardial friction rub
	Pericardial Tamponade	Acute or subacute	May last for hours to days	Sharp and stabbing retrosternal pain	Retrosternal	Worsens with deep breathing or coughing	Relieved by sitting up and leaning forward		Kussmaul sign Peripheral edema Beck triad Pulsus paradoxus
	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	Substernal heaviness or 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
Pulmonary	Pulmonary Embolism	Acute	May last minutes to hours	Sharp or knifelike or pleuritic pain Localized to side of lesion	Localized to side of lesion	Increased on respiratory movements, deep breathing or cough	Not specific	Not specific	Dyspnea tachypnea Hemoptysis 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	Acute	May last minutes to hours	Sharp Pleuritic		Increased on respiratory movements, deep breathing	Not specific	Not specific
	Pneumonia	Acute or chronic	Variable	Dull	Localized to side of lesion	Increased on respiratory movements, deep breathing	Not specific	Not specific
	Tracheitis/ Bronchitis	Acute	Variable	Dull	Substernal
	Pleuritis	Acute or subacute or 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 or subacute or chronic	Variable	Substernal pressure like	Substernal	Not specific	Not specific	Not specific	Dyspnea Symptoms of right heart failure (edema)
	Pleural Effusion	Acute or subacute or chronic	Variable
	Asthma & COPD	Acute or subacute or chronic	Variable
	Pulmonary Malignancy	Chronic	Week to months
	Sarcoidosis	Chronic	Days to week
	Acute chest syndrome	Acute	May last minutes to hours
Gastrointestinal	GERD, Peptic Ulcer	Acute	Minutes to hours (gastroesophageal reflux) Prolonged (peptic ulcer)	Burning Substernal Epigastric	Substernal Epigastric	Alcohol Aspirin Post meal Lying down Morning Empty stomach	Antiacid Food	Not specific	Not specific
	Diffuse Esophageal Spasm	Acute	Minutes to hours	Burning Pressure Retrosternal	Retrosternal	Not specific	Sublingual nitroglycerine	Not specific	Not specific
	Esophagitis	Acute	Variable	Burning Epigastric	Epigastric	Immunosuppression alcohol smoking Excessive vomiting Radiation	Acid supression therapy Proton pump inhibitors Topical pain medication	Back	Not specific
	Eosinophilic Esophagitis	Chronic	Variable	Burning Retrosternal Abdominal	Retrosternal Abdominal	Cold and dry climates European ancestry	Proton pum inhibitors Corticosteroids Biologicals Amino acid-based diet	Not specific	Alergic diseases Asthma Rinithis Eczema
	Esophageal Perforation	Acute	Minutes to hours	Burning Upper abdominal	Upper abdominal	Excessive vomiting Weight lifting alcohol	Intravenos fluids Antibiotics Nasogastric suction NPO	Back Left shoulder	Eating disorders such as bulimia
	Mediastinitis	Acute, Chronic	Variable	Retrosternal irritation	Retrosternal	Recent chest surgery Smoking obesity endoscopy	Not specific	Not specific
	Cholelithiasis	Acute, subacute	Minutes to hours	Burning Colicky Right upper abdomen Substernal epigastric	Right upper abdomen Substernal epigastric	Post meal Fatty food	Analgesics	Radiates to shoulder	Obesity Fertile females
	Pancreatitis	Acute, Chronic	Variable	Epigastric Upper left side of the abdomen Pressure like	Epigastric Upper left side of the abdomen	Lying flat on the back After eating Alcohol	Analgesics	Back Below the left shoulder	Primary cirrhosis Primary sclerosing cholangitis
	Sliding Hiatal Hernia	Acute	Variable	Epigastric Burning	Epigastric	Recumbent position Inspiration	Proton pump inhibitors H-2 blokers	Back	Obstruction Cameron ulcers
Musculoskeletal	Rib pain
	Costosternal syndromes (costochondritis)
	Lower rib pain syndromes
	Sternalis syndrome
	Tietze's syndrome
	Xiphoidalgia
	Spontaneous sternoclavicular subluxation
	Posterior chest wall pain syndromes
Rheumatic	Fibromyalgia
	Rheumatoid arthritis
	Ankylosing spondylitis
	Psoriatic arthritis
	Sternocostoclavicular hyperostosis (SAPHO syndrome)
	Systemic lupus erythematosus
	Relapsing polychondritis
Psychiatric	Panic attack/ Disorder
	Other Psychotic disorders
Others	Substance abuse (Cocaine)
	Referred pain
	Herpes Zoster
	Domestic abuse
	Stress fracture
	Sickle cell disease