Aortic dissection differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2]Cafer Zorkun, M.D., Ph.D. [3]

Overview

Aortic dissection is a life threatening entity that must be distinguished from other life threatening entities such as cardiac tamponade, cardiogenic shock, myocardial infarction, and pulmonary embolism. An aortic aneurysm is not synonymous with aortic dissection. Aneurysms are defined as a localized permanent dilation of the aorta to a diameter > 50% of normal.

Differentiating Aortic Dissection from other Diseases

Differentiating Aortic Dissection from other Diseases on the Basis of Chest Pain

The following table outlines the major differential diagnoses of Chest Pain..^[1]^[2]^[3]^[4]^[5]^[6]^[7]^[8]^[9]^[10]^[11]^[12]^[13]^[14]^[15]^[16]^[17]^[18]^[19]^[20]^[21]^[22]^[23]^[24]^[25]^[26]^[27]^[28]^[29]^[30]^[31]^[32]^[33]^[34]^[35]^[36]

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), late gadolinium enhancement (LGE); right ventricular hypertrophy (RVH), right atrial enlargement (RAE), functional tricuspid regurgitation (TR), Pulmonary artery systolic pressure (PASP; adenosine deaminase (ADA); Serum amyloid A (SAA), soluble interleukin-2 receptor (sIL2R); High-resolution CT (HRCT) scanning <zchanges | style="background: #F5F5F5; padding: 5px;" |

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

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CT angiography
Digital subtraction aortography (if high suspicion)

Sharp & localized retrosternal pain

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Pericardial friction rub

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Pericardial friction rub heard with the diaphragm of stethoscope

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EKG changes (typically widespread ST segment elevation or PR depressions)

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Chest x-ray typically normal
Echocardiogram: normal or pericardial effusion
CT scan: Noncalcified pericardial thickening with pericardial effusion
CMR: inflamed pericardium and myocarditis

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Sharp and stabbing retrosternal pain

| style="background: #F5F5F5; padding: 5px;" | +/- | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" |

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HIV
TB
Immunosuppression
Acute trauma

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Creatine kinase and isoenzymes
Abnormal LFTs
Antinuclear antibody assay, erythrocyte sedimentation rate and rheumatoid factor
HIV testing

| style="background: #F5F5F5; padding: 5px;" |EKG findings:

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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)

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Echocardiography

Sharp & localized retrosternal pain reflects associated pericarditis

| style="background: #F5F5F5; padding: 5px;" | +/- | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" |

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Serum cardiac troponin levels
↑ BNP or NT-proBNP level

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Nonspecific ST changes, single atrial or ventricular ectopic beats, complex ventricular arrhythmias

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CXR: Normal to enlarged with or without pulmonary vascular congestion and pleural effusions
Echo: Left ventricular dilation, changes in left ventricular geometry (eg, development of a more spheroid shape), and wall motion abnormalities
CMR: T1 and T2 signal intensity consistent with edema, presence of LGE consistent with necrosis or scar
Radionuclide ventriculography: ↓ EF
Cardiac catheterization: Assessment of hemodynamic status

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Endomyocardial biopsy

HF
Arrhythmias
Syncope
Acute hemodynamic collapse

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Positive family history of sudden cardiac death
Genetic mutation

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S4
Systolic murmurs
LV apical impulse
Brisk carotid pulse
↑ JVP
A parasternal lift

| style="background: #F5F5F5; padding: 5px;" |Non-specific | style="background: #F5F5F5; padding: 5px;" |

Prominent abnormal Q waves
P wave abnormalities
Left axis deviation
Deeply inverted T waves

| style="background: #F5F5F5; padding: 5px;" | Echocardiography:

LV hypertrophy
Systolic anterior motion of the mitral valve,
LVOT obstruction

Cardiac catheterization
- Pressure gradient
- Augmentation of the gradient
- Aortic pressure
- Left ventricular pressure
- Left atrial or pulmonary capillary wedge pressure
Coronary angiography
- Obstructive epicardial coronary artery disease
- Genetic testing for HCM: Sarcomere mutation in an athlete with a maximal LV wall thickness in the "grey zone"

Substernal heaviness or tightness

| style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" |

Setting of physical or emotional stress or critical illness

| style="background: #F5F5F5; padding: 5px;" |Stress | style="background: #F5F5F5; padding: 5px;" |

Murmurs and rales may be present on auscultation in the setting of acute pulmonary edema

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ST segment elevation
ST depression
QT interval prolongation, T wave inversion, abnormal Q waves

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Radionuclide myocardial perfusion imaging: Transient perfusion abnormalities in the left ventricular apex

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Ventriculography and invasive coronary angiography

Heaviness/pressure/ tightness/squeezing/ burning (Levine's sign)
Retrosternal

| style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" |

Dyspnea and decreased exercise tolerance
Dizziness and syncope
Angina pectoris

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HTN
Old age

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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

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Schistiocytes on peripheral blood smear

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Non specific (the voltage of the QRS complex is increased showing the presence of left ventricular hypertrophy)

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Echocardiography: aortic leaflets thickened and calcified, ↑ pulmonary artery pressure)
CMR: Myocardial fibrosis, evaluation of aortic anatomy and size
MDCT: Degree of aortic valve calcification
PET: Measures active mineralization which correlates with stenosis severity

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- Echocardiography

Dull
Left sided chest pain

| style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | +/- | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" |

| style="background: #F5F5F5; padding: 5px;" |Dyslipidemia, hypertension, smoking, family history of premature disease, and diabetes | style="background: #F5F5F5; padding: 5px;" |

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Hyponatremia
Hypoalbuminemia
↑ Serum brain natriuretic peptide (BNP) or NT-proBNP level
A mild elevation in serum bilirubin (total bilirubin <3 mg/dL)

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EKG findings are specific according to each cause of heart failure
Q waves, ST and T wave abnormalities in patients with prior MI
New onset arrhythmias (atrial fibrillation and ventricular tachycardia)

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CXR: Cardiomegaly
Echocardiography: ↓ EF
Right heart catheterization: Pulmonary capillary wedge pressure >20 mmHg, right atrial pressure ≥12 mmHg) and/or decreased cardiac index (≤2.2 L/min/m2

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Echocardiography

Sharp or knifelike or pleuritic pain
Localized to side of lesion

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Hemoptysis
History of venous thromboembolism or coagulation abnormalities.

| style="background: #F5F5F5; padding: 5px;" | Hormone replacement therapy Cancer Oral contraceptive pills Stroke Pregnancy Postpartum Prior history of VTE Thrombophilia | style="background: #F5F5F5; padding: 5px;" |

S3 or S4 gallop
Low grade fever
Tachycardia
Tachypnea
Hypoxia

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↑D-dimer ≥500 ng/mL
Arterial blood gases (Respiratory alkalosis)
↑Troponin levels
Hypercoagulation workup

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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)

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Duplex Ultrasonography: DVT
CXR: Westermark sign, Hampton hump, Palla's sign
Echocardiography:
- RV dilation (ratio of apical 4-chamber RV diameter to left ventricle (LV) diameter > 0.9)
- RV systolic dysfunction
Ventilation-Perfusion Scanning: High probability

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CT pulmonary angiography

Sharp
Localized pleuritic

| style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" |

Respiratory distress
Tachypnea
Asymmetric lung expansion
Hyperresonance on percussion
Decreased tactile fremitus
Tachycardia
Cardiac apical displacement

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Smoking
Positive family history
Marfan syndrome
Homocystinuria
Thoracic endometriosis.

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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

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Respiratory alkalosis on ABGs

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Rightward shift in the mean electrical axis
Loss of precordial R waves
Diminution of the QRS voltage
Precordial T wave inversions

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CXR: White visceral pleural line on the chest radiograph
CT: small amounts of intrapleural gas, atypical collections of pleural gas, and loculated pneumothoraces

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CT scan

Sharp
Pleuritic

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Trauma

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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

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Respiratory alkalosis on ABGs

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Significant elevation of the ST-T segment from leads V1 to V4

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CXR: A distinct shift of the mediastinum to the contralateral side, collapse of the ipsilateral lung, and flattening or inversion of the ipsilateral hemidiaphragm

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CT scan

Dull
Localized to side of lesion

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Altered mental status
Tachycardia
Rust-colored sputum
Green sputum
Red currant-jelly sputum
Central cyanosis

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Long hospital stay
Ill contact exposure
Aspiration

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Sinus tachycardia
Nonspecific ST-segment or T-wave changes

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CXR: Interstitial infiltrates, lobar consolidation, cavitation

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CXR

Dull
Substernal

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Inspiratory stridor (with or without expiratory stridor)
Nasal flaring
Wheezing

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Gram stain of exudates: Neutrophils

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Peaked P-wave

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Radiography of the neck: Steeple sign
Laryngotracheobronchoscopy: a normal epiglottis with subglottic narrowing, thick and purulent secretions in the trachea, pseudomembranes

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Endoscopy

Sharp
Localized pleuritic

| style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" |

Sharp chest pain with breathing
Itching in sites on the back
Dizziness

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Autoimmune conditions
Infections

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Tachypnea
Tachycardia
Pleural Rubs
Decreased breath sounds

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EKG done to rule out other causes in differential diagnoses

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Chest X Ray: Pleural fluid on one or both sides
Computerized tomography (CT) scan: Pleural effusions

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CXR

Substernal pressure like

| style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" |

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Smoking
HF
Heavy snoring
Morbid obesity

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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

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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

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Chest Radiography: Oligemic lung fields
Echocardiography: PASP is >50 and the TRV is >3.4
Ventilation-Perfusion (V/Q) Lung Scanning: Abnormal
Right-sided cardiac catheterization: Mean PCWP >15 mmHg,

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Cardiac catheterization

Dull
Pleuritic pain

| style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | +/- | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | +/- | style="background: #F5F5F5; padding: 5px;" |

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Pneumonia

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Diminished or inaudible breath sounds
Pleural friction rub
Egophony (known as "E-to-A" changes)

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Typically not indicated

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Chest X Ray: Pleural fluid on one or both sides
Computerized tomography (CT) scan: Detects small pleural effusions, ie, less than 10 mL and possibly as little as 2 mL of liquid in the pleural space, Thickening of the visceral and parietal pleura
MRI: Characterize the content of pleural effusions

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Computed tomography

Tightness

| style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | +/- | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | +/- | style="background: #F5F5F5; padding: 5px;" |

Cyanosis

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Smoking
HF
HTN

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Elevated jugular venous pulse (JVP)
Hyperinflation (barrel chest)
Peripheral edema
Clubbing
Wheezing
Rhonchi
Diffusely decreased breath sounds
Coarse crackles beginning with inspiration

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Peaked P-wave
Reduced amplitude of the QRS complexes
Multifocal atrial tachycardia (MAT)

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CXR: Hyperinflation
Spirometry: ↓ FEV1, PEF, ↓ FEV1/FVC

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Spirometry

Dull aching

| style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | +/- | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" |

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Smoking
Metastasis

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Wheeze
Crackles
Depending upon complications caused by the spread of cancer

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Hypercalcemia

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EKG may be performed before cancer treatment to identify any pre-existing conditions, or during treatment to check for possible heart damage

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CXR and CT scan: Mass lesion, hilar lymphadenopathy
Spirometry: ↓Vt, ↑RV
Bronchoscopy: Biopsy

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Bronchoscopy

Chest fullness

| style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" |

Löfgren syndrome (fever, bilateral hilar lymphadenopathy (BHL), and polyarthralgias)
Uveitis
Heart block
Lymphocytic meningitis
Diabetes insipidus
Fatigue
Hypercalciuria

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Black population
Autoimmune diseases

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Diminished respiratory sounds

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↑ ACE level, adenosine deaminase, SAA, sIL2R
Hypercalciuria
Elevated 1,25-dihydroxyvitamin D levels

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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

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Chest radiograph: Bilateral hilar adenopathy
High-resolution CT (HRCT) scanning of the chest: Ground glass opacification, Hilar and mediastinal lymphadenopathy, Bronchial wall thickening

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Lung Biopsy

Chest tightness

| style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | +/- | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" |

Sickle cell anemia
Vaso-occlusive crisis
Pain crises

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↑ WBC
↑ Hb levels
↓ fetal hemoglobin levels
Smoking
Vaso-occlusive pain events

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Systolic murmur may be heard over the entire precordium

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EKG typically not indicated

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Plain radiography of the extremities: Avascular necrosis

| style="background: #F5F5F5; padding: 5px;" | --- |- style="background: #4479BA; color: #FFFFFF; text-align: center;" ! rowspan="3" |Differentials on the basis of Etiology ! rowspan="3" |Disease ! colspan="10" |Clinical manifestations ! colspan="4" |Diagnosis |- style="background: #4479BA; color: #FFFFFF; text-align: center;" | colspan="8" |Symptoms | rowspan="2" |Risk factors ! rowspan="2" |Physical exam ! rowspan="2" |Lab Findings ! rowspan="2" |EKG ! rowspan="2" |Imaging ! rowspan="2" |Gold standard |- style="background: #4479BA; color: #FFFFFF; text-align: center;" !Onset !Duration !Quality of Pain !Cough !Fever !Dyspnea !Weight loss !Associated Features |- style="background: #DCDCDC; padding: 5px;" | | rowspan="9" |Gastrointestinal !GERD, Peptic Ulcer^[92]^[93]^[94] | style="background: #F5F5F5; padding: 5px;" |Acute | style="background: #F5F5F5; padding: 5px;" |

Minutes to hours (gastroesophageal reflux)
Prolonged (peptic ulcer)
5 to 60 minutes

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Visceral, substernal, worse with recumbency, no radiation, relief with food, antacids
Hematemesis or melena resulting from gastrointestinal bleeding
Dyspepsia

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Prolonged NSAIDs intake
Smoking
Alcohol abuse
Spicy foods
H-pylori infection

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Not any auscultatory findings associated with this disease
Enamel erosion or other dental manifestations

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EKG usually normal but may show T wave inversions in leads V2 through V4 consistent with myocardial ischemia in patients with peptic ulcer perforation

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Upper Gastrointestinal Endoscopy: Biopsy
Esophageal Manometry: To exclude an esophageal motility disorder
Esophageal impedance pH testing: Monitors esophageal pH

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Upper Gastrointestinal Endoscopy

Minutes to hours
5 to 60 minutes

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Burning
Pressure
Visceral, spontaneous, substernal

| style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" | +/- | style="background: #F5F5F5; padding: 5px;" | +/- | style="background: #F5F5F5; padding: 5px;" |

Associated with cold liquids
Relief with nitroglycerin

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Barium swallow: Multiple areas of spasm throughout the length of the esophagus
Impedance testing: Higher amplitudes and better transit of swallowed boluses

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No ECG findings associated with DES, but ECG is done to exclude variant angina due to higher concurrent association of variant angina with DES

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Esophageal manometry : ≥20 percent premature contractions (distal latency <4.5 seconds)

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Esophageal manometry

Burning
Epigastric

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No auscultatory finding

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ECG is done to rule out acute coronary syndrome

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Double-contrast esophageal barium study (esophagography)
Endoscopy: Biopsy

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Endoscopy

Burning
Retrosternal
Abdominal

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Dysphagia
Food impaction
GERD

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No auscultatory finding in the this disease

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Elevated IgE (>114,000 units/L)
Elevated peripheral eosinophils

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Typically no finding on EKG

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Barium studies: Strictures and a ringed esophagus
Endoscopy: Stacked circular rings ("feline" esophagus) ●Strictures ●Linear furrows ●Whitish papules
Esophageal biopsy: More than 15 eosinophils per high-power field

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Esophageal biopsy

Burning
Upper abdominal

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Eating disorders such as bulimia
Repeated episodes of retching and vomiting with either recent excessive dietary or alcohol intake
Subcutaneous emphysema

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Instrumentation/surgery
Penetrating or blunt trauma
Medications, other ingestions, foreign body
Violent retching/vomiting
Hernia/intestinal volvulus/obstruction
Inflammatory bowel disease
Appendicitis
Peptic ulcer disease

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↑Serum amylase
↑C-reactive protein levels

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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

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Plain chest films or chest CT: Pneumomediastinum, Free air under the diaphragm, •Pleural effusion •Pneumothorax (Macklin effect). •Subcutaneous emphysema
Plain abdominal films (or abdominal CT scout film):The appearance of pneumoperitoneum -Free air under the diaphragm -Cupola sign (inverted cup) -Rigler sign (double-wall sign) -Psoas sign -Urachus sign

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- Confirmed by water-soluble contrast esophagram

Retrosternal irritation

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Nonspecific

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Infection
Esophageal perforation
Post operative complication

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Dysphagia
Dysphonia
Stridor
Hamman sign

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Positive organisms in sternal culture
Leukocytosis
Positive blood cultures

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Diffuse ST elevation

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CT: Localize the infection and extent of spread
MRI: Assesses vascular involvement and complications

Burning
Colicky
Right upper abdomen
Substernal
epigastric

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Obesity
Fertile females in 40's

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The presence of a common bile duct stone on transabdominal ultrasound

•Clinical acute cholangitis •A serum bilirubin greater than 4 mg/dL (68 micromol/L) | style="background: #F5F5F5; padding: 5px;" |

Murphy sign negative
Jaundice

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↑ALT
↑AST
↑Amylase levels
↑ALP

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Typically not indicated

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Transabdominal ultrasound (TAUS): shows gallstones
EUS: Detects biliary sludge
MRCP: Detects stones >6mm
Endoscopic Retrograde Cholangiopancreatography (ERCP): Diagnostic and therapeutic removal of stones

Epigastric
Upper left side of the abdomen
Pressure like

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Primary cirrhosis
Primary sclerosing cholangitis
Cystic fibrosis
Autoimmune diseases

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Alcohol abuse
Smoking
Genetic predisposition

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Tachypnea
Hypoxemia
Hypotension
Cullen's sign
Grey Turner sign

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↑Amylase levels
↑Lipase levels
↑ALT
↑ALP
Leukocytosis

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T-wave inversion
ST-segment depression
ST-segment elevation rarely
Q-waves

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CT: focal or diffuse enlargement of the pancreas
MRI: Pancreatic enlargement

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CT Scan

Epigastric
Burning

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Obstruction
Cameron ulcers
GERD
Dysphagia

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Trauma
Iatrogenic
Congenital malformation

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Bowel sounds may be heard in the chest

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Non specific

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T wave inversion in anterior lead.

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Barium swallow: At least three rugal folds traversing the diaphragm
Upper endoscopy: A greater than 2-cm separation between the squamocolumnar junction and the diaphragmatic impression
High resolution manometry: The separation of the crural diaphragm from the lower esophageal sphincter (LES) by a pressure trough

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Upper endoscopy
High resolution manometry (for smaller hernias)

Pressure like on anterior part of chest wall

| style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" |

History of repeated minor trauma or unaccustomed activity (eg, painting, moving furniture)

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Trauma

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Pain by palpation of tender areas
Maneuvers, such as the "crowing rooster" and horizontal arm flexion maneuver

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Non specific

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EKG is done to rule out other cardiovascular causes

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CXR: To rule out fracture

Aching
Lower chest
Upper abdomen

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Common in women with a mean age in the mid-40s

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Hooking maneuver
Reproduces pain by pressing a tender spot on the costal margin

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Non specific
The workup is done for excluding cardiac disorders and other causes of chest pain

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EKG is done to rule out other cardiovascular causes

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CXR: To rule out fracture

| style="background: #F5F5F5; padding: 5px;" | --- |- style="background: #DCDCDC; padding: 5px;" | !Sternalis syndrome | style="background: #F5F5F5; padding: 5px;" |Chronic | style="background: #F5F5F5; padding: 5px;" |Variable | style="background: #F5F5F5; padding: 5px;" |Pressure like pain

Over the body of sternum
Sternalis muscle
Left or middle side of the chest wall

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Cardiac diseases

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Daily activities
Emotional distress
Anxiety

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Localized tenderness is found directly over the body of the sternum or overlying sternalis muscle

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No specific diagnostic test for this disease
The workup is done for excluding cardiac disorders and other causes of chest pain

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EKG is done to rule out other cardiovascular causes

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X-ray : To rule out fracture

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Physical exam

Costosternal joint
Sternoclavicular joint
Costochondral joint
Second and third ribs

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Most often involve the areas of 2nd and 3rd ribs
More common in young adults
Sternocostoclavicular hyperostosis
Ankylosing spondylitis

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Upper respiratory infections
Excessive coughing

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Painful and localized swelling of the costosternal, sternoclavicular, or costochondral joints most often involving 2nd and 3rd ribs

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No specific diagnostic test for this disease
The workup is done for excluding cardiac disorders and other causes of chest pain

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EKG is done to rule out other cardiovascular causes

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X-ray: To rule out fracture

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Tests are done to rule out other diseases

Over the xiphoid process
Sternum
Xiphisternal joint

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Symptoms are aggravated by twisting and bending movements

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Cough
Heavy work

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Provocative test

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No specific diagnostic test for this disease
The workup is done for excluding cardiac disorders and other causes of chest pain

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EKG is done to rule out other cardiovascular causes

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X-ray: To rule out fracture

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Tests are done to rule out other diseases

More common in middle age women
Occurs in dominant hands with repetitive tasks of heavy or moderate quality

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Trauma

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Palpation of tender areas

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No specific diagnostic test for this disease
The workup is done for excluding cardiac disorders and other causes of chest pain

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EKG is done to rule out other cardiovascular causes

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X-ray: Sclerosis of the medial clavicle

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X-ray

Raynaud phenomenon (RP)
Deep ache and burning pain on
- Shoulders
- Back of the Neck
- Chest
- Lower Back
- Elbows
- Hips
- Shin
- Knees

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Presence of tenderness in soft-tissue anatomic locations

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Non specific
Normal Blood and urine test (mandatory to rule out other diseases)

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P-wave dispersions (Pd)

| style="background: #F5F5F5; padding: 5px;" | --- | style="background: #F5F5F5; padding: 5px;" | --- |- style="background: #DCDCDC; padding: 5px;" | !Rheumatoid arthritis^[135] | style="background: #F5F5F5; padding: 5px;" |Chronic | style="background: #F5F5F5; padding: 5px;" |Years | style="background: #F5F5F5; padding: 5px;" |Symmetrical joint pain in

Wrist
Fingers
Knees
Feet
Ankles

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Extra-articular involvement of other organ systems
Carpal tunnel syndrome
Tarsal tunnel syndrome

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Old age
Smoking
Autoimmune conditions

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Reduced grip strength
Rheumatoid nodules

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Positive Rheumatic Factor
Anti-CCP body
Synovial fluid analysis: WBC between 1500 and 25,000/cubicmm, low glucose, low C3 and C4 complement level.
Thrombocytosis
Anemia
Mild leukocytosis

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ECG is done rule out the heart failure as RA is one of the causes of heart failure

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Plain film radiography: periarticular osteopenia, joint space narrowing, and bone erosions
MRI: Bone erosions
Ultrasonography: Degree of inflammation and the volume of inflamed tissue

| style="background: #F5F5F5; padding: 5px;" | --- |- style="background: #DCDCDC; padding: 5px;" | !Ankylosing spondylitis^[136]^[137]^[138]^[139] | style="background: #F5F5F5; padding: 5px;" |Chronic | style="background: #F5F5F5; padding: 5px;" |Years | style="background: #F5F5F5; padding: 5px;" |Intermittent pain in

Spine joint
Sacroiliac joint

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Patients with HLA-27 variant
Extra-articular joint involvements
Restrictive pulmonary disease
Acute coronary syndromes (ACS), strokes, venous thromboembolism, conduction abnormalities

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Genetics (Monozygotic twins)

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Tenderness of the SI
Limited spinal ROM
Schober test

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↑ESR
↑CRP
↑ALP
↑IgA
Antigen HLA-27 positive
Negative Rheumatic Factor

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ECG is done to rule out conductions defects and aortic insufficiency

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Plain radiography: Erosions, ankylosis, changes in joint width, or sclerosis.
Magnetic resonance imaging (MRI): Osteitis" or "bone marrow edema" (BME)

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Plain films of the sacroiliac joints

Interphalangeal joints
Nails
Wrist
Knees
Ankles
Lower Back

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Psoriasis
HLA-B*27 positive

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Dactylitis with sausage digits
Onycholysis
Pitting edema
Ocular involvement

| style="background: #F5F5F5; padding: 5px;" |Non specific | style="background: #F5F5F5; padding: 5px;" |

Longer PR interval

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X-ray: "pencil-in-cup" deformity, erosive changes and new bone formation, lysis of the terminal phalanges; fluffy periostitis
MRI: Detects articular, periarticular, and soft-tissue inflammation, enthesitis

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X-ray

Palmoplantar pustulosis (PPP)

| style="background: #F5F5F5; padding: 5px;" | Positive family history of:

Spondyloarthritis
IBD
Psoriasis
Rheumatoid arthritis
Other autoimmune/autoinflammatory disease

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Hyperostosis
Osteitis
Synovitis
Pustular eruptions
Inflammatory nodules or plaques

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Serologic testing to exclude other diseases
Non specific

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ECG is done to rule out conductions defects and aortic insufficiency

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Plain radiography: Hyperostotic changes (thickening of periosteum, cortex, and endosteum), sclerotic lesions, osteolysis, periosteal reaction, and osteoproliferation
Bone scan: "bull's head" change
Magnetic resonance imaging: Osteitis and soft tissue involvement
Fluorodeoxyglucose positron emission tomography (FDG-PET)/CT: Differentiates active versus inactive lesions

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Bone scan

Skin
Joints (fingers, wrist, knees)
Kidneys
SLE can affect any organ of the body

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HLA-genetic mutations
Female gender
Being younger than 50

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Autoimmune conditions
Genetic predisposition
Positive family history

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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

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Elevation of autoantibodies (ANA, anti-dsDNA, anti-SM, antiphospholipid)
Complement levels decreased
Anemia

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Sinus tachycardia, ST segment changes, and ventricular conduction disturbances

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Related to specific organ involvent

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Anti-dsDNA antibody test

Tissues that cover the end of the joints
Cartilage of costal rib

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Autoimmune diseases

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Physical examinations findings are seen related to nasal chondritis, ocular inflammation, cardiovascular disease, skin disease, CNS and pulmonary system

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Negative rheumatoid factor
Anti-type II collagen antibodies
Antineutrophil cytoplasmic antibodies

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ECG is done to rule out the cardiovascular complications of this disease

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Non specific
Related to specific organ involvent

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No gold standard test for this disease

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Psychiatric disorders

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Anxious
Tachypneic

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Thyroid function tests
Complete blood count
Chemistry panel

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Sinus Tachycardia

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No any specific radiographic test is done

| style="background: #F5F5F5; padding: 5px;" | --- |- style="background: #DCDCDC; padding: 5px;" | | rowspan="2" | Others !Substance abuse (Cocaine)^[150]^[151]^[152] | style="background: #F5F5F5; padding: 5px;" |Acute (hours) | style="background: #F5F5F5; padding: 5px;" |Minutes to hours | style="background: #F5F5F5; padding: 5px;" |Pressure like pain in the center of chest | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" |

| style="background: #F5F5F5; padding: 5px;" |

Psychiatric disorders

| style="background: #F5F5F5; padding: 5px;" |

Serum biomarkers (Troponin I, Troponin T)
Toxicologic tests or drug screens of bodily fluids (blood, urine, saliva) and hairs

| style="background: #F5F5F5; padding: 5px;" |

- QT prolongation
- Sinus Tachycardia
- Arrhythmias
- Cardiac conduction abnormalities

| style="background: #F5F5F5; padding: 5px;" | --- | style="background: #F5F5F5; padding: 5px;" |

Gold standard test depends on the type of substance is abuse

Chest
Upper back
Lower back

| style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" | + | style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" | - | style="background: #F5F5F5; padding: 5px;" |

People who had chickenpox

| style="background: #F5F5F5; padding: 5px;" |

Immunosuppression

| style="background: #F5F5F5; padding: 5px;" |

Painful grouped herpetiform vesicles on an erythematous base distributed in a single dermatome

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Viral culture
Direct immunofluorescence testing,
Polymerase chain reaction assay (PCR)

| style="background: #F5F5F5; padding: 5px;" |

ECG is done to rule out other cardiovascular causes of chest pain

| style="background: #F5F5F5; padding: 5px;" |

Magnetic resonance imaging (MRI): To rule out encephalitis

| style="background: #F5F5F5; padding: 5px;" |

Viral tissue culture

|}The following table outlines the major differential diagnoses of Chest Pain..^[1]^[2]^[3]^[4]^[5]^[6]^[7]^[8]^[9]^[10]^[11]^[12]^[13]^[14]^[15]^[16]^[17]^[18]^[19]^[20]^[21]^[22]^[23]^[24]^[25]^[26]^[27]^[28]^[29]^[30]^[31]^[32]^[33]^[34]^[35]^[36]

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), late gadolinium enhancement (LGE); right ventricular hypertrophy (RVH), right atrial enlargement (RAE), functional tricuspid regurgitation (TR), Pulmonary artery systolic pressure (PASP; adenosine deaminase (ADA); Serum amyloid A (SAA), soluble interleukin-2 receptor (sIL2R); High-resolution CT (HRCT) scanning

References

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Aortic dissection differential diagnosis

Overview

Differentiating Aortic Dissection from other Diseases

Differentiating Aortic Dissection from other Diseases on the Basis of Chest Pain

References

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