Chest pain dd
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Here is a comprehensive differential diagnosis of chest pain, organized by system, drawn from multiple authoritative textbooks.
Differential Diagnosis of Chest Pain
⚠️ Life-Threatening "Must Not Miss" Causes
These must be rapidly excluded in every patient presenting with chest pain:
| Diagnosis | Key Features |
|---|---|
| Acute Coronary Syndrome (ACS/MI) | Crushing/pressure-like pain, radiation to arm/jaw, diaphoresis, nausea; ECG changes, troponin rise |
| Aortic Dissection | Tearing/ripping pain radiating to the back; may mimic angina or involve coronary arteries; BP differential between arms |
| Pulmonary Embolism | Pleuritic pain, dyspnea, tachycardia, hypoxia; risk factors (DVT, immobility, malignancy) |
| Tension Pneumothorax | Sudden pleuritic pain, absent breath sounds, tracheal deviation, hemodynamic compromise |
| Esophageal Perforation | Severe pain after vomiting or instrumentation; mediastinitis; subcutaneous emphysema |
| Cardiac Tamponade | Dull chest pain, Beck's triad (hypotension, JVD, muffled heart sounds); pulsus paradoxus |
🫀 Cardiovascular (Non-ACS)
| Diagnosis | Key Features |
|---|---|
| Stable Angina | Exertional, relieved by rest/nitrates; predictable pattern |
| Prinzmetal (Variant) Angina | Coronary vasospasm; may occur at rest; ST elevation on ECG during episode |
| Pericarditis | Sharp pleuritic pain, worse lying flat, better leaning forward; pericardial friction rub; diffuse ST elevation/PR depression |
| Myocarditis | Chest pain + dyspnea in young patient; often post-viral; troponin elevation |
| Hypertrophic Cardiomyopathy (HCM) | Exertional chest pain from subendocardial ischemia |
| Aortic Stenosis | Anginal chest pain with severe AS; classic triad: angina, syncope, dyspnea |
| Mitral Valve Prolapse | Atypical chest pain; mid-systolic click |
| Cocaine Use | Coronary vasospasm + thrombosis; may cause MI in young patients |
🫁 Pleuropulmonary
| Diagnosis | Key Features |
|---|---|
| Pleuritis/Pleurisy | Sharp, positional, worsens with inspiration; pleural rub |
| Pneumonia | Pleuritic pain, fever, cough, infiltrate on CXR |
| Pneumothorax | Sudden onset sharp pain, ipsilateral decreased breath sounds |
| Pulmonary Hypertension | Exertional chest pain with dyspnea; right heart strain |
| Malignancy (e.g., mesothelioma, lung cancer) | Persistent pain, weight loss, hemoptysis |
| Tracheobronchitis | Substernal burning/rawness with cough; triggered by infection or irritant inhalation |
🍽️ Gastrointestinal
| Diagnosis | Key Features |
|---|---|
| GERD / Reflux Esophagitis | Burning, worse after meals/lying down; responds to antacids; can mimic angina (also responds to nitrates!) |
| Esophageal Spasm | Severe, episodic, may respond to nitrates (mimics angina closely) |
| Biliary Colic / Cholecystitis | RUQ/epigastric pain radiating to right shoulder; post-fatty meal; Murphy's sign |
| Peptic Ulcer Disease | Epigastric pain, relationship to food; Helicobacter pylori |
| Pancreatitis | Epigastric/lower chest pain radiating to back; elevated lipase |
| Achalasia / Esophageal Motility Disorders | Dysphagia + chest pain; regurgitation |
🦴 Musculoskeletal / Chest Wall
| Diagnosis | Key Features |
|---|---|
| Costochondritis | Reproducible tenderness on palpation of costochondral junctions; no ECG changes |
| Rib Fracture | Trauma history; point tenderness; crepitus |
| Muscle Injury / Myalgia | History of exertion or strain; reproducible with palpation/movement |
| Thoracic Outlet Syndrome | Arm pain + paresthesias; positional |
| Cervical Radiculopathy | Dermatomal distribution; neck movement triggers it |
🧠 Neurological / Dermatological
| Diagnosis | Key Features |
|---|---|
| Herpes Zoster | Dermatomal burning/lancinating pain; vesicular rash (may precede rash by days) |
| Neuritis / Radiculitis | Shooting pain in dermatomal distribution |
🩸 Systemic / Metabolic
| Diagnosis | Key Features |
|---|---|
| Severe Anemia | O₂ supply-demand mismatch → anginal-type pain |
| Thyrotoxicosis | Increased myocardial demand → angina; palpitations, weight loss, heat intolerance |
| Sickle Cell Crisis | Vaso-occlusive pain in chest; acute chest syndrome |
| Collagen Vascular Disease (e.g., SLE) | Pleuritis, pericarditis, myocarditis |
| Familial Mediterranean Fever | Recurrent serositis episodes with fever |
🧠 Functional / Psychiatric
| Diagnosis | Key Features |
|---|---|
| Panic Disorder / Anxiety | Atypical chest tightness, palpitations, hyperventilation; all workup normal |
| Functional (Non-cardiac) Chest Pain | Diagnosis of exclusion; often has psychiatric comorbidity |
| Mediastinitis | Rare; post-surgical or post-esophageal perforation |
Clinical Approach Summary
History clues:
- Quality: crushing → cardiac; tearing → dissection; burning → GI/cardiac; sharp/pleuritic → pulmonary/pericarditis; dermatomal → zoster
- Radiation: left arm/jaw → ACS; back → dissection; right shoulder → biliary
- Triggers: exertion → angina/HCM; meals → GERD; inspiration → pleurisy/PE; palpation → musculoskeletal
- Relieved by: nitrates → angina (but also esophageal spasm!); antacids → GERD; leaning forward → pericarditis
Immediate workup: 12-lead ECG (first), troponins, CXR, O₂ saturation; consider D-dimer, CT-A if dissection/PE suspected.
Sources: Washington Manual of Medical Therapeutics; Rosen's Emergency Medicine; Murray & Nadel's Textbook of Respiratory Medicine; Goldman-Cecil Medicine
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