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
		Pain characteristics							Associated Features	Auscultation Findings	Lab Findings	Imaging	Gold standard
		Onset	Duration	Type of Pain	Location	Exacerbating Factors	Alleviating Factors	Radiation
Cardiac	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 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	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	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	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	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
Pulmonary	Pulmonary Embolism
	Spontaneous Pneumothorax
	Tension Pneumothorax
	Pneumonia
	Tracheitis/ Bronchitis
	Pleuritis
	Pulmonary Hypertension
	Pleural Effusion
	Asthma & COPD
	Pulmonary Malignancy
	Sarcoidosis
	Acute chest syndrome
Gastrointestinal	GERD, Peptic Ulcer
	Diffuse Esophageal Spasm
	Esophagitis
	Eosinophilic Esophagitis
	Esophageal Perforation
	Mediastinitis
	Cholelithiasis
	Pancreatitis
	Sliding Hiatal Hernia
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