92.Classification of non-cardiogenic chest pain.
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non-cardiac chest pain musculoskeletal gastrointestinal pulmonary psychiatric differential diagnosis
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Here is a comprehensive classification of non-cardiogenic chest pain:
Classification of Non-Cardiogenic Chest Pain
Non-cardiogenic chest pain refers to chest pain arising from causes other than myocardial ischemia or primary cardiac disease. It accounts for a significant proportion of chest pain presentations and spans multiple organ systems.
I. Pulmonary / Pleural Causes
| Condition | Key Features |
|---|---|
| Pulmonary embolism (PE) | Sudden pleuritic pain, dyspnea, tachycardia; life-threatening |
| Pneumothorax | Sudden sharp unilateral pain, absent breath sounds |
| Pleuritis / Pleurisy | Sharp pain worsened by breathing and coughing |
| Pneumonia / Pleuropneumonia | Fever, productive cough, pleuritic pain |
| Pulmonary hypertension | Exertional chest pain mimicking angina |
| Tracheobronchitis | Substernal burning, worsened by coughing |
| Malignancy (lung/pleural) | Persistent, progressive pain |
II. Gastrointestinal Causes
This is one of the most common causes of non-cardiogenic chest pain.
| Condition | Key Features |
|---|---|
| Gastroesophageal reflux disease (GERD) | Burning substernal pain, worse after meals/lying down; may mimic angina |
| Esophageal spasm | Severe, squeezing chest pain; may be relieved by nitrates |
| Esophageal hypersensitivity | Pain without structural abnormality; visceral hypersensitivity |
| Achalasia / Esophageal motility disorders | Dysphagia + chest pain |
| Esophageal rupture (Boerhaave syndrome) | Severe pain after vomiting; life-threatening |
| Peptic ulcer disease | Epigastric/lower chest pain, associated with meals |
| Cholecystitis / Biliary colic | Right-sided or epigastric pain radiating to the back or shoulder |
| Pancreatitis | Severe epigastric/lower chest pain, radiates to the back |
| Hiatal hernia | Postprandial substernal discomfort |
III. Musculoskeletal Causes
(Harrison's, p. 535)
| Condition | Key Features |
|---|---|
| Costochondritis (Tietze syndrome) | Tenderness at costochondral junctions; reproducible with palpation |
| Chest wall strain / Intercostal muscle cramp | Pain related to movement or exertion |
| Cervical radiculopathy | Prolonged aching in upper chest and arm; worsened by neck movement |
| Brachial plexus compression (cervical rib) | Upper chest and arm pain |
| Fibromyalgia | Diffuse musculoskeletal pain, chest involvement |
| Rib fracture | Trauma history; point tenderness |
| Shoulder tendinitis/bursitis | Left shoulder pain may mimic anginal radiation |
| Thoracic outlet syndrome | Compression of neurovascular bundle |
IV. Vascular (Non-Cardiac) Causes
| Condition | Key Features |
|---|---|
| Aortic dissection | Tearing/ripping pain radiating to the back; pulse differentials — life-threatening |
| Aortic aneurysm | Chronic deep aching chest/back pain |
| Subclavian steal syndrome | Arm exercise-induced chest and arm pain |
Note: Aortic dissection and PE are included here as non-cardiogenic vascular emergencies — they must be excluded early in any chest pain evaluation alongside ACS.
V. Neurological / Dermatological Causes
| Condition | Key Features |
|---|---|
| Herpes zoster (Shingles) | Dermatomal burning/shooting pain; precedes rash by days |
| Intercostal neuralgia | Persistent burning in a dermatomal distribution |
| Neuropathic pain (diabetic, post-thoracotomy) | Burning, dysesthetic quality |
VI. Psychiatric / Functional Causes
These represent a major category, particularly in patients with recurrent chest pain and normal workup.
| Condition | Key Features |
|---|---|
| Panic disorder / Anxiety | Acute chest tightness, palpitations, dyspnea, fear of dying |
| Depression | Chronic, atypical chest pain with somatic symptoms |
| Somatization disorder | Multiple unexplained physical symptoms including chest pain |
| Functional chest pain (previously NCCP) | Esophageal or non-esophageal; no structural cause; visceral hypersensitivity |
| Hyperventilation syndrome | Chest tightness + dyspnea + perioral paresthesias |
VII. Other / Miscellaneous Causes
| Condition | Key Features |
|---|---|
| Anemia | Exertional chest tightness from reduced oxygen delivery |
| Thyrotoxicosis | High-output state causing chest discomfort/palpitations |
| Drug-induced (cocaine, stimulants) | Vasospasm or myocarditis-like presentation |
| Mediastinal pathology (lymphoma, thymoma, abscess) | Persistent deep chest pressure |
| Breast pathology | Chest wall pain, mastitis |
Summary: Systematic Framework
Non-Cardiogenic Chest Pain
├── Pulmonary / Pleural
├── Gastrointestinal (most common non-cardiac cause)
├── Musculoskeletal
├── Vascular (non-cardiac) — includes life-threatening aortic/PE causes
├── Neurological / Dermatological
├── Psychiatric / Functional
└── Miscellaneous (metabolic, drug-induced, mediastinal)
Key clinical principle: Even after non-cardiogenic etiology is suspected, life-threatening causes (PE, aortic dissection, tension pneumothorax, esophageal rupture) must be excluded first before attributing pain to benign causes. (Non-Invasive Imaging in Coronary Syndromes, p. 14; Harrison's, p. 535)
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