Chest pain
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I now have rich content from multiple authoritative sources. Here is a comprehensive overview of the differential diagnosis of chest pain:
Differential Diagnosis of Chest Pain
Chest pain is one of the most common and clinically important presenting complaints. Its differential is broad, spanning life-threatening emergencies to benign self-limiting conditions. The evaluation hinges on accurate characterization of the pain and systematic exclusion of dangerous etiologies.
⚠️ Life-Threatening Causes (Must Exclude First)
| Condition | Key Features |
|---|---|
| Acute Coronary Syndrome (ACS) | Pressure/squeezing substernal pain, radiation to jaw/arm, diaphoresis, nausea; may be atypical in women/diabetics/elderly |
| Aortic Dissection | Sudden, tearing/ripping pain radiating to the back; BP differential between arms; may involve coronary ostia |
| Pulmonary Embolism (PE) | Pleuritic pain, dyspnea, tachycardia, hypoxia; risk factors include immobility, DVT, malignancy |
| Tension Pneumothorax | Sudden pleuritic pain, dyspnea, absent breath sounds, tracheal deviation, hemodynamic instability |
| Esophageal Perforation | Severe chest pain after retching or instrumentation; subcutaneous emphysema, fever |
| Myopericarditis | Sharp chest pain, may mimic STEMI on ECG, typically younger patients |
— Rosen's Emergency Medicine, Ch. 64
🫀 Cardiovascular (Non-ACS)
| Condition | Notes |
|---|---|
| Stable Angina | Exertional, relieved by rest/nitrates; O₂ supply-demand mismatch |
| Prinzmetal (Variant) Angina | Coronary vasospasm; may occur at rest or with exertion/emotional stress |
| Pericarditis | Sharp, pleuritic; worsens supine, improves leaning forward; friction rub; diffuse saddle-shaped ST elevation |
| Hypertrophic Cardiomyopathy (HCM) | Exertional subendocardial ischemia; young athletes |
| Aortic Stenosis | Angina with severe AS; classical triad: angina, syncope, heart failure |
| Mitral Valve Prolapse | Atypical chest pain, sharp/stabbing, often in young women |
| Cocaine Use | Coronary vasospasm and/or thrombosis |
| Eisenmenger Syndrome | Chest pain with pulmonary hypertension and right-to-left shunting |
— Washington Manual of Medical Therapeutics; Murray & Nadel's Respiratory Medicine
🫁 Pulmonary
| Condition | Notes |
|---|---|
| Pulmonary Embolism | Pleuritic pain ± hemoptysis; tachycardia; look for DVT |
| Pleuritis/Pleurisy | Sharp, well-localized, worsens with inspiration and cough |
| Pneumothorax | Sudden unilateral pleuritic pain; absent breath sounds |
| Pneumonia | Pleuritic pain with fever, cough, infiltrate on CXR |
| Pulmonary Hypertension | Exertional chest pressure/pain, dyspnea, right heart strain |
| Tracheobronchitis | Substernal burning/rawness with cough |
| Malignancy / Mesothelioma | Progressive, often dull, associated with weight loss |
| Sickle Cell Disease | Acute chest syndrome — pain, fever, hypoxia |
— Murray & Nadel's Textbook of Respiratory Medicine, Table 38.1
🍽️ Gastrointestinal
| Condition | Notes |
|---|---|
| GERD / Reflux Esophagitis | Burning retrosternal pain; worse postprandially; may respond to nitroglycerin (mimics angina) |
| Esophageal Spasm | Substernal squeezing/pressure; may radiate to jaw/arms; responds to nitrates — easily confused with ACS |
| Peptic Ulcer Disease | Epigastric/lower chest pain; food may relieve or worsen |
| Biliary Colic / Cholecystitis | Right upper quadrant or epigastric pain radiating to right shoulder; gallstones on US |
| Pancreatitis | Epigastric pain radiating to back; elevated lipase |
| Esophageal Perforation (Boerhaave) | Severe pain after vomiting; surgical emergency |
— Washington Manual; Rosen's Emergency Medicine
🦴 Musculoskeletal
| Condition | Notes |
|---|---|
| Costochondritis | Tenderness on palpation of costochondral junctions; reproducible on exam |
| Rib Fracture | Trauma history; point tenderness; worsened by breathing |
| Cervical/Thoracic Radiculopathy | Dermatomal distribution; may radiate to chest |
| Muscle Strain / Myalgia | History of exertion; positional; reproducible |
| Herpes Zoster | Burning, dermatomal, unilateral — precedes rash |
🧠 Other / Miscellaneous
| Condition | Notes |
|---|---|
| Anemia | Myocardial O₂ supply-demand mismatch; exertional angina-like pain |
| Thyrotoxicosis | Increased cardiac demand; can precipitate or mimic angina |
| Anxiety / Panic Disorder | Atypical pain, palpitations, hyperventilation; diagnosis of exclusion |
| Mediastinitis | Severe pain; post-surgical or post-instrumentation |
| Thoracic Outlet Syndrome | Pain radiating to arm/shoulder with positional arm elevation |
| Ingested Foreign Body | Especially in children; atypical dysphagia with pain |
Clinical Approach: Key Discriminators
| Feature | Suggests |
|---|---|
| Pressure, radiation to jaw/arm, diaphoresis | ACS |
| Tearing, abrupt onset, back radiation | Aortic dissection |
| Pleuritic, dyspnea, tachycardia | PE or pneumothorax |
| Positional (worse supine), friction rub | Pericarditis |
| Reproducible with palpation | Costochondritis |
| After eating, burning, relieved by antacids | GERD |
| Dermatomal, burning, no rash yet | Herpes zoster |
| Young athlete, exertional | HCM or aortic stenosis |
Any patient with acute chest pain should have ACS, aortic dissection, PE, and pneumothorax excluded before considering non-life-threatening diagnoses.
Sources:
- Washington Manual of Medical Therapeutics — Table 4-3
- Rosen's Emergency Medicine — Ch. 64
- Murray & Nadel's Textbook of Respiratory Medicine — Table 38.1
- Braunwald's Heart Disease
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