chest pain (gastrointestinal, coronary artery diseases musculoskeletal, psychogenic), and differential diagnosis
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Chest Pain: Causes and Differential Diagnosis
Chest pain is among the most challenging presentations in clinical medicine because visceral afferent fibers from the heart, lungs, great vessels, and esophagus enter the same thoracic dorsal ganglia — producing overlapping, indistinct pain quality and location that makes differentiation difficult without systematic evaluation.
— Rosen's Emergency Medicine, p. 257
1. Coronary Artery Disease (Ischemic/Cardiac)
Pathophysiology
Chest discomfort is the cardinal manifestation of myocardial ischemia, resulting from coronary artery disease or any condition that creates an imbalance between myocardial oxygen demand and supply.
— Goldman-Cecil Medicine, Ch. 39
Classic Angina (Diamond-Forrester Criteria — all 3 required)
- Substernal pressure-like quality (patients often describe: pressure, tightness, squeezing, heaviness, burning — rarely the word "pain")
- Precipitated by exertion, emotional stress, cold, or heavy meals
- Relieved by rest or nitroglycerin within < 30 minutes
Radiation to the neck, jaw, left shoulder, or arm is characteristic. Symptoms lasting > 30 minutes without troponin elevation argue strongly against angina.
— Fuster & Hurst's The Heart, 15th Ed.
Angina Subtypes
| Type | Features |
|---|---|
| Stable angina | Predictable, exertional; lasts 2–10 min; relieved by rest/NTG |
| Unstable angina | Rest pain or new-onset/worsening; may progress to MI |
| Variant (Prinzmetal) angina | Coronary vasospasm; occurs at rest or with exertion |
| Walk-through angina | Rare — pain improves with continued exercise |
Acute Coronary Syndromes
- NSTEMI/Unstable angina: clinically indistinguishable except UA may be more activity-related and more rapidly responsive to therapy
- STEMI: pain usually > 30 min; elevated troponin; ST elevation on ECG
- Aortic dissection can mimic angina and may involve coronary arteries; classically sudden-onset tearing/ripping pain radiating to the back, associated with hypertension
Other Cardiac Causes
- Pericarditis: pleuritic, sharp; worsened supine, relieved leaning forward; pericardial friction rub
- HCM / Aortic stenosis: subendocardial ischemia with exertion
- Cocaine use: coronary vasospasm and/or thrombus formation
2. Gastrointestinal Causes
GI causes account for 30–40% of noncardiac chest pain, with esophageal disorders being the most common identifiable source.
— Murray & Nadel's Respiratory Medicine
Esophageal Disease
| Condition | Key Features |
|---|---|
| GERD | Burning, retrosternal; post-prandial; worsened supine; relieved by antacids; lasts 10–60 min |
| Esophageal spasm | Intense squeezing; 2–30 min; can mimic angina; may radiate to arms; can be relieved by nitroglycerin (important trap) |
| Nutcracker esophagus | High-amplitude peristaltic contractions; substernal aching |
| Achalasia | Dysphagia + retrosternal pain/pressure |
| Boerhaave's syndrome | Esophageal rupture after vomiting; severe retrosternal pain; mediastinitis |
| Eosinophilic esophagitis | Young patients; dysphagia, food impaction |
Key distinguishing points for esophageal pain:
- Chest discomfort lasting > 1 hour, with residual dull aching
- Associated heartburn, odynophagia, or dysphagia
- Worsened after meals; improved with antacids or PPIs
- Pain can radiate to neck and arms (esophageal afferents travel T3–T12)
Clinical trap: Nitroglycerin relieves both myocardial ischemia and esophageal spasm — a trial of NTG does not confirm cardiac disease. — Goldman-Cecil Medicine
Other GI Causes
| Condition | Features |
|---|---|
| Peptic ulcer disease | Epigastric burning, 60–90 min post-meals; relieved by food/antacids |
| Cholecystitis / Biliary colic | RUQ/epigastric pain radiating to right shoulder/back; post-fatty meal; can be visualized on ultrasound |
| Acute pancreatitis | Severe epigastric pain radiating to back; elevated lipase/amylase |
3. Musculoskeletal Causes
Musculoskeletal disorders account for 10–20% of noncardiac chest pain.
— Murray & Nadel's Respiratory Medicine
Conditions
- Costochondritis — tenderness at costochondral/chondrosternal junctions; may have localized swelling or redness (Tietze syndrome when swollen)
- Cervical disk/radiculopathy — pain radiates from neck to chest/arm; sensory deficits possible
- Subacromial bursitis — shoulder pain referred to anterior chest
- Intercostal muscle cramps / strain — associated with coughing, trauma, recent exertion
- Rib fracture — history of trauma
- Herpes zoster — dermatomal distribution; precedes rash by days; burning
Distinguishing features
- Sharp, highly localized, positional pain
- Completely reproduced by light-to-moderate palpation of the chest wall, or by specific movements
- History of recent trauma, chest infection, or vigorous coughing
Important caveat: Chest wall tenderness on palpation does not exclude myocardial ischemia — it is present in a subset of ACS patients. A positive Tietze/palpation sign supports musculoskeletal etiology but does not rule out cardiac disease. — Harrison's Principles, 22nd Ed.
4. Psychogenic / Psychiatric Causes
Psychological factors may explain up to 50% of undiagnosed noncardiac chest pain cases, and approximately 25% of patients presenting to the ED with chest pain have panic disorder — which frequently goes undiagnosed, leading to repeated expensive cardiac evaluations.
— Murray & Nadel's; Rosen's Emergency Medicine
Panic Disorder
Recurrent, discrete episodes of intense fear with ≥4 of:
- Chest pain or discomfort (often crushing, mimics MI)
- Dyspnea, palpitations, diaphoresis
- Trembling, nausea, dizziness
- Paresthesias, chills/hot flushes
- Fear of dying or losing control
Pain is typically described as atypical — often in younger women. Associated hyperventilation can produce non-specific ST-T changes on ECG, further complicating diagnosis.
Other Psychiatric Causes
- Generalized anxiety disorder — diffuse worry with intermittent chest tightness
- Somatic symptom disorder — persistent chest complaints without identifiable organic cause
- Depression — somatic presentations are common
- PTSD — chest pain as a somatic symptom
Mitral valve prolapse can coexist with panic disorder and cause palpitations indistinguishable from panic attacks. — Murray & Nadel's
Differential Diagnosis Summary Table
| Category | Key Diagnoses | Classic Features |
|---|---|---|
| Coronary / Cardiac | Stable/unstable angina, STEMI, NSTEMI, pericarditis, dissection | Substernal pressure; radiation to arm/jaw; exertional; ECG changes; troponin elevation |
| Gastrointestinal | GERD, esophageal spasm, PUD, biliary colic, pancreatitis | Post-prandial; burning; relieved by antacids; dysphagia; epigastric |
| Musculoskeletal | Costochondritis, rib fracture, cervical radiculopathy, zoster | Localized; positional; reproducible on palpation/movement |
| Psychogenic | Panic disorder, anxiety, somatic symptom disorder | Atypical; episodic; younger patients; associated with fear, palpitations, paresthesias |
| Pulmonary | PE, pneumothorax, pneumonia/pleuritis, pulmonary HTN | Pleuritic; dyspnea; tachycardia; hypoxia |
| Vascular | Aortic dissection | Sudden, tearing; back radiation; pulse differentials; HTN |
Diagnostic Approach
History (highest yield — 80–90% of diagnoses)
- Onset: sudden (dissection, PE, pneumothorax) vs. gradual (ischemia, GERD)
- Quality: pressure/squeezing (cardiac) vs. burning (GERD) vs. sharp/positional (musculoskeletal/pleuritis) vs. tearing (dissection)
- Location and radiation: substernal + arm/jaw (cardiac); epigastric/sternal + back (GI); dermatomal (zoster)
- Duration: < 5 min (angina) vs. minutes–hours (MI, GI) vs. hours–days (pericarditis, musculoskeletal)
- Precipitants: exertion (angina, PE, pulmonary HTN); meals (GI); movement/palpation (musculoskeletal); spontaneous (panic, esophageal spasm, rest angina)
- Relief: NTG (cardiac or esophageal spasm); antacids (GI); analgesics/NSAIDs (musculoskeletal)
Initial Investigations
| Test | What it detects |
|---|---|
| ECG (within 10 min) | STEMI, ischemia, pericarditis, PE changes (S1Q3T3) |
| Troponin (high-sensitivity) | Myocardial injury (serial measurements 0 + 3h) |
| Chest X-ray | Pneumothorax, pneumonia, mediastinal widening, pulmonary edema |
| D-dimer / CTA pulmonary | Pulmonary embolism |
| CT aortogram | Aortic dissection |
| Upper endoscopy / pH study | GERD, esophagitis, esophageal motility disorders |
| Abdominal ultrasound | Biliary disease |
| Stress testing | Stable suspected CAD |
Sources:
- Goldman-Cecil Medicine, 26th Ed., Chs. 39, 123
- Harrison's Principles of Internal Medicine, 22nd Ed., Ch. on chest pain evaluation
- Fuster & Hurst's The Heart, 15th Ed., Ch. 2
- Murray & Nadel's Textbook of Respiratory Medicine, noncardiac chest pain section
- Rosen's Emergency Medicine, Table 22.1
- Tintinalli's Emergency Medicine, chest pain and panic disorder sections
- Sleisenger & Fordtran's GI and Liver Disease, Ch. 46 (GERD)
- Washington Manual of Medical Therapeutics, Table 4-3
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