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Chest Pain: Gastrointestinal, Coronary Artery Disease, Musculoskeletal, and Psychogenic Causes

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1. Coronary Artery Disease (CAD) / Acute Coronary Syndrome

Stable Angina

• Character: Pressure, squeezing, or constriction - maximal intensity retrosternally or over the left parasternal border
• Radiation: Neck, jaw, shoulder, or down the inner arm (one or both)
• Triggers: Exercise, heavy meals, excitement, extreme emotion
• Duration: 2-10 minutes; resolves with rest or sublingual nitroglycerin (NTG)
• Risk factors: Hypertension, diabetes mellitus, hyperlipidemia, smoking, family history

Unstable Angina / NSTEMI

• Anginal pain occurring at rest, with new onset, or with increasing frequency/severity
• Warrants urgent evaluation (a "must not miss" diagnosis)

STEMI (Acute MI)

• Same location as angina but much more severe
• Not relieved by rest or nitroglycerin; requires opiates
• Associated with: profuse diaphoresis, nausea, dyspnea, profound weakness
• ECG: ST elevation (>1 mm in 2 contiguous leads; specific thresholds apply by sex/age in V2-V3)
• Elevated troponin, possible CXR vascular congestion

Prinzmetal / Variant Angina

• Similar quality and location to typical angina, but occurs at rest
• Caused by epicardial coronary vasospasm, often on non-critical stenosis
• Managed with coronary angiography and provocative testing if needed

Stress Cardiomyopathy (Takotsubo)

• Angina-like pain, ischemic ECG changes, elevated biomarkers - but no culprit obstructive lesion
• Hallmark: apical ballooning with basal hypercontractility
• Often triggered by emotional or physical stress; typically resolves over weeks to months

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2. Gastrointestinal Causes

Gastroesophageal Reflux Disease (GERD)

• Extremely common cause of chest pain; sometimes indistinguishable from angina
• Character: burning, substernal; may radiate similarly to cardiac pain
• Provocants: lying down after meals, large/fatty meals, tobacco, alcohol, chocolate, coffee, peppermint (lower esophageal sphincter relaxants)
• Associated symptoms: heartburn, regurgitation, chronic cough, hoarseness
• Important: Relief with nitroglycerin is seen in 55% of esophageal chest pain AND 62% of cardiac pain - NTG response does not differentiate the two
• Diagnosis: suspicious history + endoscopic findings has 97% specificity; empiric PPI trial is often diagnostic

Esophageal Spasm / Motility Disorders

• Substernal chest pain, often intermittent, with dysphagia
• Can be triggered by exercise, stress, or food temperature
• ECG may show nonspecific ST-T changes
• Management: reduce spasm, treat coexisting GERD, relieve outflow obstruction

Esophagitis / Esophageal Ulcer

• Often causes odynophagia (pain on swallowing)
• Causes: GERD, infection (Candida, HSV), pill esophagitis (bisphosphonates, tetracyclines, NSAIDs, potassium)

Esophageal Rupture (Boerhaave Syndrome)

• Acute, severe chest pain after forceful retching
• Medical emergency; CXR may show mediastinal emphysema

Peptic Ulcer Disease

• Epigastric/lower chest discomfort; can radiate upward
• Worsened or relieved by food depending on ulcer location

Biliary Colic / Cholecystitis

• RUQ or epigastric pain, may radiate to right shoulder or chest
• Often postprandial (especially with fatty foods)
• Diagnosed with abdominal ultrasound

Pancreatitis

• Severe epigastric pain radiating to the back; may be perceived as lower chest pain
• Elevated lipase/amylase, epigastric tenderness

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3. Musculoskeletal Causes

Costochondritis

• Pain from inflammation of the costochondral cartilaginous junctions
• Character: dull, gnawing, aching quality
• Most common at 2nd, 3rd, and 4th costochondral junctions
• Tenderness to palpation clearly localized - this is the diagnostic key
• Little relationship to breathing or body movement

Tietze Syndrome

• Similar to costochondritis but with visible/palpable redness, swelling, and enlargement of costal cartilages
• Typically affects a single joint (usually 2nd or 3rd costochondral)

Precordial Catch Syndrome

• Sharp, well-localized chest pain, typically in young patients
• Brief duration (seconds to minutes), worsened by deep inspiration
• Benign; self-limiting

Intercostal Neuritis / Radiculitis

• Originates from cervicodorsal spine disorders or nerve root compression (C4-T6)
• Character: superficial, spontaneous, lancinating or "electric shock" quality
• Follows cutaneous dermatome distribution
• Worsened by deep breathing, coughing, sneezing
• Hyperalgesia or anesthesia on skin examination
• May evolve into herpes zoster vesicular rash 2-3 days later

Herpes Zoster

• Dysesthetic, sharp, unilateral chest pain preceding or accompanying vesicular rash over a thoracic dermatome

Rib Fracture

• Localized pain with clear relationship to trauma (may be minor, e.g., coughing)
• Worsened by movement, deep inspiration, palpation

Pectoral Muscle Strain / Myositis

• History of vigorous physical activity
• Pain worsened by movement, palpation of involved muscles

Cervical / Thoracic Spondylosis (C4-T6)

• Referred pain to chest from degenerative spine disease
• May be associated with arm paresthesias or neck stiffness

Fibromyalgia / Rheumatologic disorders

• Ankylosing spondylitis, fibrositis can produce diffuse chest wall pain
• Part of broader musculoskeletal syndrome

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4. Psychogenic / Functional Causes

Panic Disorder

• Chest pain (often sharp or pressure-like), palpitations, dyspnea, diaphoresis
• Associated with intense fear, derealization, tingling, lightheadedness
• Eyes often closed during episodes (vs. true syncope where eyes are open)
• Preceded by overwhelming anxiety
• Diagnosis of exclusion after ruling out organic causes (Rosen's Emergency Medicine)

Anxiety and Somatization

• Chest pain may accompany generalized anxiety disorder
• Poorly localized, variable character, often with multiple somatic complaints
• History of depression, anxiety, prior functional symptoms

Functional Chest Pain (Previously "Psychogenic Chest Pain")

• DSM-5 classifies under Somatic Symptom Disorder (SSD)
• Evolution: DSM-III called it "psychogenic pain" → DSM-III-R "somatoform pain disorder" → DSM-IV "pain disorder" → DSM-5 merged into SSD
• Characterized by disproportionate thoughts, feelings, and behaviors related to pain
• Often diagnosed after extensive negative workup (Kaplan & Sadock's Comprehensive Textbook of Psychiatry)

Key Features Suggesting Psychogenic Chest Pain

• Pain is atypical in character, location, or radiation
• Variable, inconsistent triggers
• High level of health anxiety
• History of psychiatric illness
• Multiple negative cardiac and GI workups
• Pain relieved by distraction or anxiolytics

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Differential Diagnosis Table

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Clinical Approach Summary

1. Exclude life-threatening causes first: ACS, aortic dissection, PE, esophageal rupture, tension pneumothorax
2. History is key - character, onset, duration, radiation, triggers, relieving factors, and associated symptoms
3. Point tenderness on chest wall exam favors musculoskeletal but does not exclude cardiac
4. NTG response is unreliable for distinguishing esophageal from cardiac pain (both respond ~60%)
5. GI workup should only begin after cardiac causes are excluded
6. Psychiatric/functional diagnoses are diagnoses of exclusion
7. Tools: 12-lead ECG (serial), high-sensitivity troponin, HEART score, chest X-ray, D-dimer, lipase, abdominal ultrasound, empiric PPI trial for GERD

• Murray & Nadel's Textbook of Respiratory Medicine, Chest Pain Syndromes, Table 38.1 & 38.2
• Symptom to Diagnosis: An Evidence-Based Guide, 4th Ed., Chapter 9
• Rosen's Emergency Medicine, ACS Differential Diagnoses
• The Washington Manual of Medical Therapeutics, CAD and GERD sections
• Kaplan & Sadock's Comprehensive Textbook of Psychiatry, Somatic Symptom Disorder