Chest pain

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chest pain differential diagnosis diagram

I now have comprehensive information from multiple authoritative sources. Here is a thorough overview of the differential diagnosis of chest pain:

Differential Diagnosis of Chest Pain

Chest pain is one of the most common and diagnostically challenging presentations in medicine. The proximity of multiple thoracic organs and the overlap in visceral pain referral patterns make precise attribution difficult. The key clinical principle is to first exclude life-threatening causes, then systematically work through the remaining diagnoses.

⚠️ Life-Threatening Causes (Exclude First)

These must always be considered when evaluating any chest pain patient:

Condition	Key Features
Acute Coronary Syndrome (ACS/STEMI/NSTEMI)	Crushing substernal pressure, radiation to arm/jaw, diaphoresis, nausea; risk factors: age, HTN, DM, smoking
Aortic Dissection	Sudden, tearing/ripping pain radiating to the back; BP differential between arms; may mimic angina or involve coronary ostia
Pulmonary Embolism (PE)	Pleuritic chest pain + dyspnea + tachycardia; risk factors: immobility, DVT, malignancy
Tension Pneumothorax	Sudden pleuritic pain, absent breath sounds, tracheal deviation, hypotension
Esophageal Perforation	Severe pain after vomiting or instrumentation; mediastinal air on imaging (Boerhaave syndrome)
Myopericarditis	Chest pain in young patients, may follow viral illness; elevated troponin, diffuse ST changes

Cardiovascular (Non-ACS)

Stable Angina / Vasospastic (Prinzmetal) Angina — episodic exertional or rest pain from coronary supply-demand mismatch or vasospasm; responsive to nitroglycerin
Pericarditis — sharp pleuritic pain, worse lying flat, relieved leaning forward; friction rub; diffuse saddle-shaped ST elevation
Hypertrophic Cardiomyopathy (HCM) — exertional angina from subendocardial ischemia; associated with syncope
Aortic Stenosis — anginal episodes in severe AS due to increased LV afterload
Mitral Valve Prolapse — atypical chest pain, often in young women; associated with palpitations
Cocaine-induced ischemia — coronary vasospasm and/or thrombosis; mimics ACS

Pulmonary / Pleuropulmonary

Pleurisy — sharp, localized pain worsened with breathing, coughing, or trunk movement; arises from parietal pleural inflammation. Diaphragmatic pleural involvement refers to the ipsilateral shoulder (via phrenic nerve)
Pneumonia — pleuritic pain with fever, productive cough, consolidation on CXR
Pneumothorax — sudden-onset sharp unilateral pain + dyspnea; immediate onset suggests spontaneous or traumatic
Pulmonary Hypertension — crushing substernal pain resembling angina; occurs with exertion
Malignancy (e.g., mesothelioma) — gradual onset with systemic features
Tracheobronchitis — rawness or tightness from airway irritation or infection
Sickle Cell Disease — acute chest syndrome (vaso-occlusion in pulmonary vasculature)

Gastrointestinal

GERD / Reflux Esophagitis — burning substernal discomfort; can mimic angina and is even partially relieved by nitroglycerin. Difficult to distinguish from ischemia without testing
Esophageal Spasm / Motility Disorders — substernal chest pain is the main symptom in 80–90% of cases; may radiate, worsen with swallowing
Peptic Ulcer Disease / Gastritis — epigastric to lower sternal pain, related to meals
Biliary Colic / Cholecystitis — RUQ or epigastric pain, often postprandial; confirmed by abdominal ultrasound
Pancreatitis — epigastric pain radiating to the back, associated with nausea/vomiting

Musculoskeletal / Chest Wall

Costochondritis — reproducible tenderness at the costochondral junctions; worse with palpation or movement
Rib Fracture — history of trauma; localized, pleuritic, exacerbated by palpation
Muscle Injury (Myalgia) — related to activity or strain
Cervical/Thoracic Radiculopathy — dermatomal distribution, may radiate to chest from nerve root compression

Infectious / Cutaneous

Herpes Zoster (Shingles) — burning, dermatomal pain preceding the vesicular rash by days; diagnosis can be missed before the rash appears

Systemic / Metabolic

Anemia — severe anemia causes myocardial O₂ supply-demand mismatch mimicking angina
Thyrotoxicosis — increased myocardial demand can precipitate anginal symptoms or ACS

Mediastinal / Other

Mediastinitis — severe substernal pain following esophageal perforation or cardiac surgery
Thoracic Outlet Obstruction — positional arm and chest pain
Iatrogenic (post-procedure pain)

Diagnostic Approach Summary

Step	Action
History	Character (crushing vs. pleuritic vs. burning), onset, radiation, associated symptoms (dyspnea, diaphoresis, syncope)
Risk stratification	Cardiac risk factors (age, HTN, DM, smoking, family history)
12-lead ECG	Immediate; look for ST elevation (STEMI), ST depression/T-wave changes (NSTEMI/UA), or alternative diagnoses (PE, pericarditis)
Troponin	High-sensitivity troponin for myocardial injury; serial measurements if initial negative
CXR	Widened mediastinum (dissection), pneumothorax, pneumonia, cardiomegaly
Further imaging	CT angiography (dissection/PE), Echo, stress testing as indicated

Key principle: A careful history, physical exam, ECG, and cardiac biomarkers will narrow the differential in most cases. The patient's reported history remains the most important diagnostic study and must guide interpretation of all investigations.

— Rosen's Emergency Medicine, Ch. 64 | Washington Manual of Medical Therapeutics, p. 118 | Murray & Nadel's Textbook of Respiratory Medicine, Table 38.1

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