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] Amresh Kumar MD [3]

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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:

When a patient presents with chest pain, the following differentials mentioned in the table below need to be ruled out to reach the appropriate diagnosis.

Abbreviations: ABG (arterial blood gas); ACE (angiotensin converting enzyme); BMI (body mass index); CBC (complete blood count); CSF (cerebrospinal fluid); CXR (chest X-ray); ECG (electrocardiogram); FEF (forced expiratory flow rate); FEV1 (forced expiratory volume); FVC (forced vital capacity); JVD (jugular vein distention); MCV (mean corpuscular volume); Plt (platelet); RV (residual volume); SIADH (syndrome of inappropriate antidiuretic hormone); TSH (thyroid stimulating hormone); Vt (tidal volume); WBC (white blood cell); Coronary CT angiography (CCTA); multidetector row scanners (MDCT); Cardiovascular magnetic resonance — CMRI; Myocardial perfusion imaging (MPI); single-photon emission CT (SPECT); Positron emission tomography (PET) scanning; Magnetic resonance (MR) angiography, Computed tomographic (CT) angiography, and Transesophageal echocardiography (TEE)

Differentials on the basis of Etiology	Disease	Clinical manifestations										Diagnosis
		Symptoms								Risk factors	Physical exam	Lab Findings	EKG	Imaging	Gold standard
		Onset	Duration	Quality of Pain	Cough	Fever	Dyspnea	Weight loss	Associated Features
	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	Dyslipidemia, hypertension, smoking, family history of premature disease, and diabetes	Transient third heart sound (S3 - ventricular filling sound) and fourth heart sound (S4 - atrial filling sound)	Cardiac enzymes normal	Exercise EKG: ST-segment depression	Exercise Stress Testing: Decreased myocardial perfusion Transthoracic echocardiography: Ejection fraction <50 percent	Coronary angiography
	Unstable Angina	Acute	10-20 minutes	Same as stable angina but often more severe	-	-	+	-	Nausea and vomiting Diaphoresis Presyncope Palpitations	Dyslipidemia, hypertension, smoking, family history of premature disease, and diabetes	Reverse splitting of the second heart sound Rales or crackles Elevated jugular venous pressure	Cardiac biomarkers [Cardiac troponin I, cardiac troponin T and MB isoenzyme of creatine kinase (CK-MB)] normal	ST-depression New T wave inversions Transient ST-elevation	Echocardiography: Ejection fraction <50 percent Exercise Stress Testing: Decreased myocardial perfusion	Invasive coronary angiography
	Myocardial Infarction	Acute	Commonly > 20 minutes	Same as stable angina but often more severe	-	-	+	-	Nausea and vomiting Diaphoresis Presyncope Palpitations Lateral displacement of the apical impulse	Dyslipidemia, hypertension, smoking, family history of premature disease, and diabetes	Hypotension Tachycardia S4 gallop Paradoxical splitting of S2 Mitral regurgitation murmur	Elevated cardiac enzymes ↑B-Type Natriuretic Peptide	ST elevation MI (STEMI) Non-ST elevation MI (NSTEMI) or Non Q wave	Echocardiography: ↓ EF CCTA: Coronory artery stenosis CMRI: Coronory vessels stenosis MPI on SPECT or PET scanning: Decreased myocardial perfusion.	CCTA combined with MPI
Cardiac	Vasospastic/ Prinzmetal/ Variant Angina	Gradual in onset and offset	Episodic, gradual in onset and offset.	Chest discomfort described as squeezing, tightness, pressure, constriction, strangling, burning, heart burn, fullness in the chest, a band-like sensation, knot in the center of the chest, lump in the throat, ache, and heavy weight on chest	-	-	+	-	Nausea, sweating, dizziness, dyspnea, and palpitations Associated with other vasospastic disorders, such as Raynaud's phenomenon and migraine headache	Multiple drugs (ephedrine-based products, cocaine, marijuana, alcohol, butane, sumatriptan, and amphetamines) Food-born botulism Guide wire or balloon dilatation while doing PCI Magnesium deficiency	Tachycardia, hypertension, diaphoresis, and a gallop rhythm	Urine drug screen may be positive for cocaine or other drugs	Transient (less than 15 minutes) ischemic ST changes in multiple leads A tall and broad R wave, Disappearance of the S wave A taller T wave Negative U waves	Stress testing: normal noninvasive stress test, exercise-induced spasm with ST-segment elevation, Stress echocardiography with ergonovine provocation: Vasospasm of coronory vessels Coronary arteriography: Epicardial spasm	Coronary arteriography
	Aortic Dissection	Sudden severe progressive pain (common) or chronic (rare)	Variable	Tearing, ripping sensation, knife like	-	-	+	-	Focal neurologic deficit Hypotension	Hypertension Genetically mediated collagen disorders Preexisting aortic aneurysm Bicuspid aortic valve Aortic coarctation Turner syndrome Vasculitis (giant cell arteritis, Takayasu arteritis, rheumatoid arthritis, syphilitic aortitis)	Pulse deficit New diastolic murmur Diastolic decrescendo murmur Focal neurologic deficit Hypotension	D-dimer <500 ng/mL rules out aortic dissection ↑Soluble ST2 (sST2) Measurements of soluble elastin fragments, smooth muscle myosin heavy chain, high-sensitivity C-reactive protein, fibrinogen, and fibrillin fragments	Nonspecific ST and T wave changes	CXR: Mediastinal and/or aortic widening CTA: A compressed true lumen MRA: Detects differential flow between the true and false lumens, widening of the aorta with a thickened wall TEE: Intimal dissection flaps, true and false lumens, thrombosis in the false lumen Aortography: Distortion of the normal contrast column, Flow reversal or stasis into a false channel, Failure of major branches to fill, and Aortic valvular regurgitation	CT angiography Digital subtraction aortography (if high suspicion)
	Pericarditis	Acute or subacute	May last for hours to days	Sharp & localized retrosternal pain	+	+	+	-	Pericardial friction rub	HIV TB Immunosuppression Acute trauma	Pericardial friction rub heard with the diaphragm of stethoscope	Leukocytosis ↑Troponin level ↑Erythrocyte sedimentation rate ↑C-reactive protein level	EKG changes (typically widespread ST segment elevation or PR depressions)	Chest x-ray typically normal Echocardiogram: normal or pericardial effusion CT scan: Noncalcified pericardial thickening with pericardial effusion CMR: inflamed pericardium and myocarditis	Pericardiocentesis Pericardial biopsy
	Pericardial Tamponade	Acute or subacute	May last for hours to days	Sharp and stabbing retrosternal pain	+/-	+	+	-	Pulsus paradoxus Pericardial rub		Kussmaul sign Beck triad Pulsus paradoxus	Creatine kinase and isoenzymes Abnormal LFTs Antinuclear antibody assay, erythrocyte sedimentation rate and rheumatoid factor HIV testing	EKG findings: Sinus tachycardia Low QRS voltage Electrical alternans	CXR: enlarged cardiac silhouette with clear lung fields Echocardiography: Chamber collapse, Respiratory variation in volumes and flows, IVC plethora Swan-Ganz Catheterization: Equilibration of average intracardiac diastolic pressures (usually between 10 and 30 mmHg)	Echocardiography
	Myocarditis
	Hypertrophic cardiomyopathy
	Stress (takotsubo) Cardiomyopathy	Acute	Commonly > 20 minutes	Substernal heaviness or tightness	-	-	+	-	Setting of physical or emotional stress or critical illness		Murmurs and rales may be present on auscultation in the setting of acute pulmonary edema	Catecholamines transiently elevated ↑TnT level ↑BNP level	ST segment elevation ST depression QT interval prolongation, T wave inversion, abnormal Q waves	Radionuclide myocardial perfusion imaging	Ventriculography and invasive coronary angiography
	Aortic Stenosis	Acute, recurrent episodes of angina	2-10 minutes	Heaviness/pressure/ tightness/squeezing/ burning (Levine's sign) Retrosternal	-	-	+	-	Dyspnea and decreased exercise tolerance Dizziness and syncope Angina pectoris		S2 is soft, single and paradoxically split A2 delayed and tends to occur simultaneously with P2 Aortic ejection click Fourth heart sound (S4) can also be heard Crescendo–decrescendo murmur	Peripheral blood smear may show schistiocytes	Non specific (the voltage of the QRS complex is increased showing the presence of left ventricular hypertrophy)	CXR Echocardiography Cardiac Catheterization and Coronary Arteriography Radionuclide Ventriculography	Transthoracic Echo
	Heart Failure	Subacute or chronic	Variable	Dull Left sided chest pain	+	-	+	-	Orthopnea Peripheral edema Hemoptysis		S3 Elevated JVP Peripheral edema	Thyroid function tests may be abnormal ↑ Serum brain natriuretic peptide (BNP) or NT-proBNP level	EKG findings are specific according to each cause of heart failure	CXR: Cardiomegaly Radionuclide multiple-gated acquisition scanning Electrocardiogram-gated myocardial perfusion imaging Equilibrium radionuclide angiocardiography Catheterization and Angiography	Echocardiography
Differentials on the basis of Etiology	Disease	Clinical manifestations										Diagnosis
		Symptoms								Risk factors	Physical exam	Lab Findings	EKG	Imaging	Gold standard
		Onset	Duration	Quality of Pain	Cough	Fever	Dyspnea	Weight loss	Associated Features
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.		S3 or S4 gallop	↑D-dimer Arterial blood gases (Respiratory alkalosis) ↑Troponin levels	Tachycardia and nonspecific ST-segment and T-wave changes (70 percent) S1Q3T3 pattern New right bundle branch block Inferior Q-waves (leads II, III, and aVF)	Duplex Ultrasonography Echocardiography Venography Ventilation-Perfusion Scanning	CT pulmonary angiography
	Spontaneous Pneumothorax	Acute	May last minutes to hours	Sharp Localized pleuritic	-	-	+	-	Respiratory distress Tachypnea  Asymmetric lung expansion Hyperresonance on percussion Decreased tactile fremitus Tachycardia Cardiac apical displacement		Decreased breath sounds on involved side Lung sounds transmitted from the unaffected hemithorax are minimal with auscultation at the midaxillary line Adventitious lung sounds (crackles, wheeze; an ipsilateral finding) Pulsus paradoxus	Respiratory alkalosis on ABGs	Rightward shift in the mean electrical axis Loss of precordial R waves Diminution of the QRS voltage Precordial T wave inversions	CXR: White visceral pleural line on the chest radiograph Contrast-Enhanced Esophagography Computed Tomography of Chest	CT scan
	Tension Pneumothorax	Acute	May last minutes to hours	Sharp Pleuritic	-	-	+	-	Hypotension Jugular venous distention Respiratory distress		Decreased breath sounds on involved side Lung sounds transmitted from the unaffected hemithorax are minimal with auscultation at the midaxillary line Adventitious lung sounds (crackles, wheeze; an ipsilateral finding) Pulsus paradoxus	Respiratory alkalosis on ABGs	Significant elevation of the ST-T segment from leads V1 to V4	CXR: White visceral pleural line on the chest radiograph Ultrasonography Computed Tomography of Chest	CT scan
	Pneumonia	Acute or chronic	Variable	Dull Localized to side of lesion	+	+	+	+/-	Altered mental status Tachycardia Rust-colored sputum Green sputum Red currant-jelly sputum Central cyanosis		Wheezing Rhonchi Rales Decreased breath sounds Pleural friction rub	Arterial blood gas : Hypoxia, hypoxemia Venous blood gas determination ↑ Procalcitonin Complete blood cell (CBC) count with differential: Leukocytosis Sputum evaluation Positive blood cultures PCR	Sinus tachycardia Nonspecific ST-segment or T-wave changes	CXR: lung infiltrates Chest CT Scanning Bronchoscopy with or without BAL	Presence of lung infiltrates on CXR Blood cultures
	Tracheitis/ Bronchitis	Acute	Variable	Dull Substernal	+	+	+	-	Tachypnea Respiratory distress Hoarseness Dyspnea Cyanosis Sore throat Odynophagia Dysphonia		Inspiratory stridor (with or without expiratory stridor) Nasal flaring	Obtain bacterial culture and Gram stain of tracheal secretions and blood cultures	Peaked P-wave	Radiography of the neck Laryngotracheobronchoscopy	Bronchoscopy
	Pleuritis	Acute or subacute or chronic	May last minutes to hours	Sharp Localized pleuritic	+	+	+	-	Sharp chest pain with breathing Itching in sites on the back Dizziness		Pleural Rubs	Leukocytosis Arterial blood gas (ABG)  Thoracocentesis	EKG done to rule out other causes in differential diagnoses	Chest X Ray Computerized tomography (CT) scan Ultrasound	Video assisted thoracoscopic surgery
	Pulmonary Hypertension	Acute or subacute or chronic	Variable	Substernal pressure like	+	-	+	-	Dyspnea Symptoms of right heart failure (edema) Past history of heart murmur Deep venous thrombosis (DVT) Arthritis or arthralgias Rash Heavy snoring Morbid obesity		The intensity of the pulmonic component of the second heart sound (P2) may be increased and the P2 may demonstrate fixed or paradoxical splitting.  Systolic ejection murmur A right-sided fourth heart sound (S4) with a left parasternal heave	Abnormal Arterial blood gas Antinuclear antibody (ANA) levels Antineutrophil cytoplasmic antibody (ANCA) Brain natriuretic peptide (BNP of NT-proBNP) HIV testing Iron deficiency Pulmonary Function Testing Polysomnography	Right axis deviation An R wave/S wave ratio greater than one in lead V1 Incomplete or complete right bundle branch block Increased P wave amplitude in lead II (P pulmonale) due to right atrial enlargement	Chest Radiography Echocardiography Ventilation-Perfusion Lung Scanning Right-sided cardiac catheterization	Cardiac catheterization
	Pleural Effusion	Acute or subacute or chronic	Variable	Dull Pleuritic pain	+	+/-	+	+/-	Increasing lower extremity edema Orthopnea Paroxysmal nocturnal dyspnea Night sweats Hemoptysis		Diminished or inaudible breath sounds Pleural friction rub Egophony (known as "E-to-A" changes)	Pleural fluid LDH, glucose and pH CBC Pleural fluid Cell Count Differential Pleural fluid culture and cytology Pleural fluid amylase levels Pleural fluid triglyceride and cholesterol levels Pleural fluid antinuclear antibody and rheumatoid factor	Typically not indicated	CT Scanning Ultrasonography Chest Radiography Diagnostic Thoracentesis Pleural biopsy	Computed tomography
	Asthma & COPD	Acute or subacute or chronic	Variable	Tightness	+	+/-	+	+/-	Cyanosis Elevated jugular venous pulse (JVP) Peripheral edema Hyperinflation (barrel chest) Rapidity of onset Signs of atopy or allergic rhinitis Nail clubbing		Wheezing Diffusely decreased breath sounds Coarse crackles beginning with inspiration	Pulmonary function tests Arterial Blood Gas Analysis Alpha1-Antitrypsin Sputum Evaluation B-Type Natriuretic Peptide Blood and Sputum Eosinophils Serum Immunoglobulin E Pulse Oximetry Assessment Allergy Skin Testing Bronchoprovocation	Peaked P-wave Reduced amplitude of the QRS complexes Multifocal atrial tachycardia (MAT)	Chest Radiography Chest CT Scanning Electrocardiography MRI Nuclear Imaging	Spirometry
	Pulmonary Malignancy	Chronic	Week to months	Dull aching	+	+/-	+	+	Bone pain Fatigue Neurologic dysfunction Superior vena cava (SVC) obstruction Hoarseness Hemidiaphragm paralysis Dysphagia Paraneoplastic syndromes Hypercalcemia		Depending upon complications caused by the spread of cancer	Complete blood cell count Serum chemistries Transthoracic needle aspiration Thoracoscopy Serum electrolytes levels Liver function tests (LFTs) Renal function tests (RFTs) Serum lactate dehydrogenase (LDH) level Serum alkaline phosphatase (ALP) level	EKG may be performed before cancer treatment to identify any pre-existing conditions, or during treatment to check for possible heart damage	Chest radiography CT scanning of the chest and abdomen Endobronchial ultrasound (EBUS) Endoscopic ultrasound CT scanning/magnetic resonance imaging (MRI) of the brain with IV contrast Bone scanning	CT Scan
	Sarcoidosis	Chronic	Days to week	Chest fullness	+	-	+	-	Löfgren syndrome (fever, bilateral hilar lymphadenopathy (BHL), and polyarthralgias) Uveitis Heart block Lymphocytic meningitis Diabetes insipidus Fatigue Hypercalciuria		Diminished respiratory sounds	Serum amyloid A (SAA), soluble interleukin-2 receptor (sIL-2R), lysozyme, angiotensin-converting enzyme (ACE) and the glycoprotein KL-6 Elevated 1,25-dihydroxyvitamin D levels CBC LFTS Kidney function test Urine DR Carbon monoxide diffusion capacity test	AV block Prolongation of the PR interval (first-degree AV block) Ventricular arrhythmias (sustained or nonsustained ventricular tachycardia and ventricular premature beats [VPBs])  Supraventricular arrhythmias	Chest radiograph Pulmonary function tests High-resolution CT (HRCT) scanning of the chest	Lung Biopsy
	Acute chest syndrome (Sickle cell anemia)	Acute	May last minutes to hours	Chest tightness	+	+/-	+	-	Sickle cell anemia Vaso-occlusive crisis Pain crises		Systolic murmur may be heard over the entire precordium	CBC Erythrocyte sedimentation rate Peripheral blood smears The reticulocyte count Arterial blood gases Sickling test	EKG typically not indicated	Chest radiography Plain radiography of the extremities Magnetic Resonance Imaging Computed Tomography Nuclear Medicine Scans Transcranial Doppler Ultrasonography Abdominal Ultrasonography Echocardiography	---
Differentials on the basis of Etiology	Disease	Clinical manifestations										Diagnosis
		Symptoms								Risk factors	Physical exam	Lab Findings	EKG	Imaging	Gold standard
		Onset	Duration	Quality of Pain	Cough	Fever	Dyspnea	Weight loss	Associated Features
Gastrointestinal	GERD, Peptic Ulcer	Acute	Minutes to hours (gastroesophageal reflux) Prolonged (peptic ulcer) 5 to 60 minutes	Burning Substernal Epigastric	+/-	-	-	+/-	Visceral, substernal, worse with recumbency, no radiation, relief with food, antacids Hematemesis or melena resulting from gastrointestinal bleeding Dyspepsia		Not any auscultatory findings associated with this disease Enamel erosion or other dental manifestations	Serum Gastrin Level Secretin Stimulation Test Ambulatory 24-Hour pH Monitoring	EKG usually normal EKG may show T wave inversions in leads V2 through V4 consistent with myocardial ischemia in patients with peptic ulcer perforation	Upper Gastrointestinal Endoscopy Esophageal Manometry Barium esophagogram  Ambulatory reflux monitoring Nuclear Medicine Gastric Emptying Study Intraluminal Esophageal Electrical Impedance	Ambulatory pH monitoring
	Diffuse Esophageal Spasm	Acute	Minutes to hours 5 to 60 minutes	Burning Pressure Visceral, spontaneous, substernal,	+	-	+/-	+/-	Associated with cold liquids Relief with nitroglycerin		---	Blood glucose levels Hemoglobin A1C levels Esophagogastroduodenoscopy (EGD), or upper endoscopy	No ECG findings associated with DES, but ECG is done to exclude variant angina due to higher concurrent association of variant angina with DES	Barium swallow Esophageal manometry is more than 20% premature contractions CT scanning Ultrasonography	Esophageal manometry
	Esophagitis	Acute	Variable	Burning Epigastric	+	+	-	+/-	Heartburn Abdominal pain		No auscultatory finding	Troponin or other cardiac markers Complete blood (CBC) cell count CD4 count Human immunodeficiency virus (HIV) test Collagen disorder workup Blind Brush Cytology	ECG is done to rule out acute coronary syndrome for the cause of chest pain	Double-contrast esophageal barium study (esophagography) Endoscopy	Biopsy
	Eosinophilic Esophagitis	Chronic	Variable	Burning Retrosternal Abdominal	+	-	-	-	Allergic diseases Asthma Rinitis Eczema		No auscultatory finding in the this disease	Elevated IgE Elevated peripheral eosinophils Skin prick testing Blood allergy testing Atopy patch testing	Typically no finding on EKG	Barium studies Endoscopy CT scan MRI	More than 15 eosinophils per high-power field
	Esophageal Perforation	Acute	Minutes to hours	Burning Upper abdominal	-	+/-	+	-	Eating disorders such as bulimia Repeated episodes of retching and vomiting with either recent excessive dietary or alcohol intake Subcutaneous emphysema		Auscultatory findings of pleural effusion Hamman crunch (crackling sound upon chest auscultation occurs due to pneumomediastinum)	CBC Serum albumin levels Thoracentesis with examination of the pleural fluid	EKG may be indicated to assess for myocardial ischemia due to acute gastrointestinal bleeding, especially if there is coexisting:Cardiovascular disease, significant anemia and advanced age	Water-soluble contrast esophagram	Iodine, water-soluble contrast medium esophagography
	Mediastinitis	Acute, Chronic	Variable	Retrosternal irritation	+/-	+	+	-	Nonspecific		Crunching sound heard with a stethoscope over the precordium during systole called as Hamman sign	Positive organisms in sternal culture Complete blood count (CBC) Blood cultures	Diffuse ST elevation	CT Chest X-Ray Magnetic resonance imaging Nuclear medicine	---
	Cholelithiasis	Acute, subacute	Minutes to hours	Burning Colicky Right upper abdomen Substernal epigastric	-	+/-	-	-	Obesity Fertile females		Murphy sign negative	LFT's Amylase levels Llipase levels CBC	Typically not indicated	Transabdominal ultrasound (TAUS) Abdominal Radiography CT Scan Magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) Scintigraphy Endoscopic Retrograde Cholangiopancreatography (ERCP) Percutaneous Transhepatic Cholangiography (PTC)	Ultrasound
	Pancreatitis	Acute, Chronic	Variable	Epigastric Upper left side of the abdomen Pressure like	-	+	+	+/-	Primary cirrhosis Primary sclerosing cholangitis		No auscultatory finding associated with this disease	Amylase levels Lipase levels  Fecal tests LFT's Serum electrolytes BUN and creatinine Blood glucose, cholesterol, and triglycerides levels CBC C-reactive protein	T-wave inversion ST-segment depression  ST-segment elevation rarely Q-waves	CT MRI Transabdominal ultrasound ((TAUS) Abdominal radiography Endoscopic Retrograde Cholangiopancreatography Magnetic Resonance Cholangiopancreatography Image-Guided Aspiration and Drainage	CT Scan
	Sliding Hiatal Hernia	Acute	Variable	Epigastric Burning	+	-	+	-	Obstruction Cameron ulcers		No auscultatory finding associated with this disease	No any specific laboratory test is done	T wave inversion in anterior lead.	Chest radiograph Endoscopy Manometry Barium upper gastrointestinal series	Endoscopy
Musculoskeletal	Costosternal syndromes (costochondritis)	Acute, subacute	Days to weeks	Pressure like on anterior part of chest wall	-	+	-	Chest wall pain occurs with a history of repeated minor trauma or unaccustomed activity (eg, painting, moving furniture)	Palpation of tender areas		No specific diagnostic test for this disease The workup is done for excluding cardiac disorders and other causes of chest pain	EKG is done to rule out other cardiovascular causes	CXR MRI	No any gold standard test for this disease
	Lower rib pain syndromes	Chronic	Variable	Aching Lower chest Upper abdomen	-	-	+	-	Common in women with a mean age in the mid-40s		Hooking maneuver	No specific diagnostic test for this disease The workup is done for excluding cardiac disorders and other causes of chest pain	EKG is done to rule out other cardiovascular causes	CXR	No any gold standard test for this disease
	Sternalis syndrome	Chronic	Variable	Pressure like pain Over the body of sternum Sternalis muscle Left or middle side of the chest wall	-	-	-	-	Cardiac diseases		On physical examination localized tenderness is found directly over the body of the sternum or overlying sternalis muscle	No specific diagnostic test for this disease The workup is done for excluding cardiac disorders and other causes of chest pain	EKG is done to rule out other cardiovascular causes	X-ray Bone Scanning	No any gold standard test for this disease
	Tietze's syndrome	Acute	Weeks	Pressure like pain over Costosternal joint Sternoclavicular joint Costochondral joint Second and third ribs	-	-	-	-	Most often involve the areas of 2nd and 3rd ribs More common in young adults		Painful and localized swelling of the costosternal, sternoclavicular, or costochondral joints most often involving 2nd and 3rd ribs	No specific diagnostic test for this disease The workup is done for excluding cardiac disorders and other causes of chest pain	EKG is done to rule out other cardiovascular causes	X-ray MRI	Tests are done to rule out other diseases
	Xiphoidalgia	Acute	Variable	Pressure like pain over Over the xiphoid process Sternum Xiphisternal joint	-	-	-	-	Symptoms are aggravated by twisting and bending movements		Provocative test	No specific diagnostic test for this disease The workup is done for excluding cardiac disorders and other causes of chest pain	EKG is done to rule out other cardiovascular causes	X-ray	Tests are done to rule out other diseases
	Spontaneous sternoclavicular subluxation	Acute, Chronic	Variable	Aching pain over Sternoclavicular joint	-	-	-	-	More common in middle age women Occurs in dominant hands with repetitive tasks of heavy or moderate quality		Palpation of tender areas	No specific diagnostic test for this disease The workup is done for excluding cardiac disorders and other causes of chest pain	EKG is done to rule out other cardiovascular causes	CT Esclerosis in X-ray	Esclerosis in X-ray
Differentials on the basis of Etiology	Disease	Clinical manifestations										Diagnosis
		Symptoms								Risk factors	Physical exam	Lab workup	EKG	Imaging	Gold standard
		Onset	Duration	Quality of Pain	Cough	Fever	Dyspnea	Weight loss	Associated Features
Rheumatic	Fibromyalgia	Chronic	Variable	Raynaud phenomenon (RP) Deep ache and burning pain on Shoulders Back of the Neck Chest Lower Back Elbows Hips Shin Knees	-	-	+	-	Somatization Depression		Presence of tenderness in soft-tissue anatomic locations	Normal Blood and urine test (mandatory to rule out other diseases)	P-wave dispersions (Pd)	MRI	No any gold standard test is availble
	Rheumatoid arthritis	Chronic	Years	Symmetrical joint pain in Wrist Fingers Knees Feet Ankles	-	+	-	+	Extra-articular involvement of other organ systems Carpal tunnel syndrome Tarsal tunnel syndrome		Reduced grip strength Rheumatoid nodules	Positive Rheumatic Factor Anti-CCP body	ECG is done rule out the heart failure as RA is one of the causes of heart failure	Plain film radiography of the affected joints MRI Ultrasonography	No any gold standard test for diagnosis of Rheumatoid Arthritis
	Ankylosing spondylitis	Chronic	Years	Intermittent pain in Spine joint Sacroiliac joint	-	-	-	-	Patients with HLA-27 variant Extra-articular joint involvements Restrictive pulmonary disease		Tenderness of the SI Limited spinal ROM Schober test	Complete blood count (CBC) Erythrocyte sedimetation rate (ESR) Antigen HLA-27 Negative Rheumatic Factor	ECG is done to rule out conductions defects and aortic insufficiency	Computed tomography (CT) Magnetic resonance imaging (MRI) Power Doppler ultrasonography	Plain films of the sacroiliac joints
	Psoriatic arthritis	Chronic	Years	Asymmetrical intermittent pain in Interphalangeal joints Nails Wrist Knees Ankles Lower Back	-	-	-	-	Psoriasis Enthesitis Tenosynovitis Dactylitis		Dactylitis with sausage digits	Serum complement Levels of Long Prentaxin 3 protein (PTX3) Increased levels of CRP Erythrocyte sedimentation rate Rheumatoid factor Immunoglobulin	Longer PR interval	X-ray of the involved joints CT scanning MRI Ultrasonography	No any gold standard test is available for this test
	Sternocostoclavicular hyperostosis (SAPHO syndrome)	Chronic	Years	Recurrent and multifocal pain in Sternoclavicular joint	-	+	-	-	Palmoplantar pustulosis (PPP)		Depending on the type of joint affected	Serologic testing to exclude other diseases High levels of alkaline phosphatase	ECG is done to rule out conductions defects and aortic insufficiency	Plain radiography Computed tomography Bone scan Magnetic resonance imaging Positron emission tomography	No any gold standard test is available for this disease
	Systemic lupus erythematosus	Chronic	Years	Skin Joints (fingers, wrist, knees) Kidneys SLE can affect any organ of the body	-	+	+	+	HLA-genetic mutations Female gender Being younger than 50		Malar rash Photosensitive rash Discoid rash Arthritis of the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints of the hands Pleuro-pericardial friction rubs Systolic murmurs	Elevation of autoantibodies (ANA, anti-dsDNA, anti-SM, antiphospholipid) Complement levels decreased Serum creatinine Urinalysis with microscopy Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) Liver function tests Creatine kinase assay Spot protein/spot creatinine ratio	Sinus tachycardia, ST segment changes, and ventricular conduction disturbances	Joint radiography Chest X-ray CT Scan MRI Echocardiography Arthrocentesis Lumbar puncture	Anti-dsDNA antibody test
	Relapsing polychondritis	Chronic	Years	Intermittent pain in Tissues that cover the end of the joints Cartilage of costal rib	+	+	+	+	Hodkin's lymphoma Myelodysplastic syndromes Gastrointestinal disorders Type 1 Diabetes mellitus Auricular chondritis		Physical examinations findings are seen related to nasal chondritis, ocular inflammation, cardiovascular disease, skin disease, CNS and pulmonary system	Negative rheumatoid factor Biopsy Complete blood cell count (CBC) with differential Metabolic panel Serum creatinine Liver transaminase and serum alkaline phosphatase studies Urinalysis dipstick and microscopic evaluation of sediment Cryoglobulins Viral hepatitis panel Antinuclear antibody (ANA) Antineutrophil cytoplasmic antibody (ANCA)	ECG is done to rule out the cardiovascular complications of this disease	Chest radiography Spiral CT scanning FDG-PET/CT MRI Posteroanterior and lateral dye contrast pharyngotracheogram Scintigraphy	No gold standard test for this disease
Psychiatric	Panic attack/ Disorder	Acute or subacute or chronic	Variable	Variable	+	-	+	-	History of Depression Panic attacks Agoraphobia		Anxious Tachypneic	Thyroid function tests Complete blood count Chemistry panel	Sinus Tachycardia	No any specific radiographic test is done	No gold standard test for panic attack
Others	Substance abuse (Cocaine)	Acute (hours)	Minutes to hours	Pressure like pain in the center of chest	+	+	+	+	Anxiety Dyspnea Nausea Palpitations		Signs of injection drug use Signs of drug inhalation Poor personal hygiene	Serum biomarkers (Troponin I, Troponin T) Toxicologic tests or drug screens of bodily fluids (blood, urine, saliva) and hairs	QT prolongation Sinus Tachycardia Arrhythmias Cardiac conduction abnormalities	Brain CT scan	Gold standard test depends on the type of substance is abuse
	Herpes Zoster	Acute or Chronic	Variable	Burning pain on Chest Upper back Lower back	-	+	-	-	People who had chickenpox		Painful grouped herpetiform vesicles on an erythematous base distributed in a single dermatome	Nerve test Blood test	ECG is done to rule out other cardiovascular causes of chest pain	Magnetic resonance imaging (MRI)	Viral tissue culture