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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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 | ||||||
Cardiac | Stable Angina | Sudden (acute) | 2-10 minutes |
|
- | - | +/- | - |
|
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Unstable Angina | Acute | 10-20 minutes |
|
- | - | + | - |
|
||||||
Myocardial Infarction | Acute | Commonly > 20 minutes |
|
- | - | + | - |
|
Elevated cardiac enzymes | |||||
Aortic Stenosis | Acute, recurrent episodes of angina | 2-10 minutes |
|
- | - | + | - | |||||||
Aortic Dissection | Sudden severe progressive pain (common) or chronic (rare) | Variable |
|
- | - | + | - |
|
|
CXR: Mediastinal and/or aortic widening
CTA MRA TEE |
||||
Pericarditis | Acute or subacute | May last for hours to days |
|
+/- | + | + | - |
|
EKG changes (typically widespread ST segment elevation) | |||||
Pericardial Tamponade | Acute or subacute | May last for hours to days |
|
+/- | + | + | - |
|
|
EKG findings: Sinus tachycardia, low QRS voltage, and electrical alternans | ||||
Heart Failure | Subacute or chronic | Variable |
|
+ | - | + | - |
|
|
|||||
Stress (takotsubo) | Acute | Commonly > 20 minutes |
|
- | - | + | - |
|
|
|
||||
Pulmonary | Pulmonary Embolism | Acute | May last minutes to hours |
|
+ | +/- | + | - |
|
|||||
Spontaneous Pneumothorax | Acute | May last minutes to hours |
|
- | - | + | - | Decreased breath sounds on involved side | ||||||
Tension Pneumothorax | Acute | May last minutes to hours |
|
- | - | + | - | |||||||
Pneumonia | Acute or chronic | Variable |
|
+ | + | + | +/- | |||||||
Tracheitis/ Bronchitis | Acute | Variable |
|
+ | + | + | - | |||||||
Pleuritis | Acute or subacute or chronic | May last minutes to hours |
|
+ | + | + | - |
|
||||||
Pulmonary Hypertension | Acute or subacute or chronic | Variable |
|
+ | - | + | - |
|
||||||
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 |
|
|
+/- | - | - | +/- | Not specific | Ambulatory reflux monitoring | ||||
Diffuse Esophageal Spasm | Acute |
|
|
+ | - | - | +/- | Not specific | Esophageal manometry is more than 20% premature contractions | |||||
Esophagitis | Acute | Variable |
|
+ | + | - | +/- | Not specific |
|
Endoscopy | Biopsy | |||
Eosinophilic Esophagitis | Chronic | Variable |
|
+ | - | - | - | More than 15 eosinophils per high-power field | ||||||
Esophageal Perforation | Acute | Minutes to hours |
|
- | +/- | + | - | Eating disorders such as bulimia | Water-soluble contrast esophagram | |||||
Mediastinitis | Acute, Chronic | Variable |
|
+/- | + | + | - | Postive organisms in sternal culture |
|
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Cholelithiasis | Acute, subacute | Minutes to hours |
|
- | +/- | - | - |
|
|
|
||||
Pancreatitis | Acute, Chronic | Variable |
|
- | + | + | +/- |
|
|
|||||
Sliding Hiatal Hernia | Acute | Variable |
|
+ | - | + | - |
|
||||||
Musculoskeletal | Costosternal syndromes (costochondritis) | Acute, subacute | Days to weeks |
|
- | +/- | + | - |
|
|
||||
Lower rib pain syndromes | Chronic | Variable |
|
- | - | + | - |
|
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Sternalis syndrome | Chronic | Variable | Pressure like pain
|
- | - | - | - |
|
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Tietze's syndrome | Acute | Weeks | Pressure like pain over
|
|
| |||||||||
Xiphoidalgia | Acute | Variable | Pressure like pain over
|
|
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Spontaneous sternoclavicular subluxation | Acute, Chronic | Variable | Aching pain over Sternoclavicular joint |
|
| |||||||||
Rheumatic | Fibromyalgia | Chronic | Variable | |||||||||||
Rheumatoid arthritis | Chronic | Years | Symmetrical joint pain in
|
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Ankylosing spondylitis | Chronic | Years | Intermittent pain in
|
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Psoriatic arthritis | Chronic | Years | Asymmetrical intermittent pain in
|
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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 | |||||||||||||
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
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