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	EKG	Imaging	Gold standard
		Onset	Duration	Type of Pain	Cough	Fever	Dyspnea	Weight loss	Associated Features	Auscultation Findings
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
	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
	Pericarditis	Acute or subacute	May last for hours to days	Sharp & localized retrosternal pain	+/-	+	+	-	Pericardial friction rub
	Pericardial Tamponade	Acute or subacute	May last for hours to days	Sharp and stabbing retrosternal pain	+/-	+	+	-	Kussmaul sign Beck triad Pulsus paradoxus
	Heart Failure	Subacute or chronic	Variable	Dull Left sided chest pain	+	-	+	-	Orthopnea Peripheral edema Hemoptysis	S3 Elevated JVP
	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
	Diffuse Esophageal Spasm	Acute	Minutes to hours	Burning Pressure Retrosternal					Not specific
	Esophagitis	Acute	Variable	Burning Epigastric					Not specific
	Eosinophilic Esophagitis	Chronic	Variable	Burning Retrosternal Abdominal					Alergic diseases Asthma Rinithis Eczema
	Esophageal Perforation	Acute	Minutes to hours	Burning Upper abdominal					Eating disorders such as bulimia
	Mediastinitis	Acute, Chronic	Variable	Retrosternal irritation
	Cholelithiasis	Acute, subacute	Minutes to hours	Burning Colicky Right upper abdomen Substernal epigastric					Obesity Fertile females
	Pancreatitis	Acute, Chronic	Variable	Epigastric Upper left side of the abdomen Pressure like					Primary cirrhosis Primary sclerosing cholangitis
	Sliding Hiatal Hernia	Acute	Variable	Epigastric Burning					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