• Clinical science

Chest pain (Thoracic pain)

Abstract

Chest pain may indicate numerous life-threatening conditions such as myocardial infarction, pulmonary embolism, aortic dissection, and pneumothorax, and therefore should be immediately investigated. In addition to clinical red flags, ECG, laboratory tests (especially cardiac enzymes), and imaging (often chest x-ray and sometimes CT) play an important role in diagnosing the underlying condition. Once acute, life-threatening diagnoses (particularly cardiovascular and pulmonary diseases) are excluded, other causes should be investigated using additional diagnostic assessments.

Differential diagnoses

Differential diagnoses of acute chest pain

Condition Clinical features Diagnostics
Patient characteristics Symptoms/signs Location
Cardiac
Acute coronary syndrome
  • Usually older patients (> 40 years)
  • Poorly localized/retrosternal
  • Radiation to the left shoulder
Pericarditis
  • Usually in younger patients; sometimes follows a viral infection (usually a URI)
  • Sharp pain
  • Exacerbated by lying down
  • Improved by leaning forward
  • Retrosternal
  • Radiation to the left shoulder
  • Auscultation: sometimes high-pitched pericardial “squeak”
  • ECG: diffuse ST-segment elevation and/or PR-segment depression
  • ESR/CRP
Takotsubo cardiomyopathy
  • Particularly in older women
  • Heavy, dull, pressure/squeezing sensation
  • Retrosternal
  • ST-segment changes and elevated cardiac enzymes, but no evidence of coronary stenosis or occlusion on catheterization
Aortic dissection
  • Tearing pain
  • Feeling of impending doom
  • Hypotension, asymmetrical blood pressure and pulse readings between limbs
  • Chest and/or interscapular
  • CT angiography of chest ± abdomen/pelvis
  • Chest and abdominal ultrasound/x-ray
  • Unstable patients: transesophageal echocardiography (TEE) [1] https://goo.gl/GvBHW2 thd: one source sufficient
Pulmonary
Pulmonary embolism
  • History of DVT
  • Unilateral
  • Elevated D-dimer (nonspecific)
  • ECG: right ventricular strain
  • CT/MR angiography
  • V/Q scan
Pneumonia and/or pleurisy
  • Unilateral
  • Leukocytosis (nonspecific)
  • Infiltrate on chest x-ray
  • If pleurisy is present:
  • If effusion is present
    • Diminished breath sounds and dullness to percussion over the effusion
    • Chest ultrasound/x-raypleural effusion
Pneumothorax
  • History of lung disease or trauma
  • Pleuritic pain
  • Sudden onset dyspnea
  • Hyperresonance to percussion and diminished breath sounds on affected side
  • Acute hypotension if tension pneumothorax develops
  • Chest x-ray: increased lucency over pneumothorax, possibly pleural lines
  • Ultrasound: lack of lung sliding
Musculoskeletal
Costochondritis
  • May have a history of recent exercise/exertion/chest wall trauma
  • Sharp, well-localized pain
  • Variable
  • Pain reproducible with palpation
  • Responds well to NSAIDs
Gastrointestinal
Gastroesophageal reflux disease
  • May be associated with certain foods (e.g., spicy, chocolate)
  • Pressure/burning sensation
  • Increased severity in the supine position
  • Substernal
  • Endoscopy
Esophageal perforation
  • Mackler triad (chest pain, vomiting, subcutaneous emphysema)
  • Chest pain; radiating to the back
  • Chest X‑ray: shows widened mediastinum
  • If patient stable: contrast esophagram with gastrografin
  • If patient unstable: CT scan of the chest
Mallory‑weiss syndrome
  • Repeated episodes of severe vomiting
  • Hematemesis
  • Epigastric pain, radiating to the back
  • Esophagogastroduodenoscopy
Peptic ulcer disease
  • NSAID intake
  • Helicobacter pylori-associated gastritis
  • Possible hematemesis and tarry stools
  • If duodenal: pain relieved with food
  • If gastric: pain worsens after meals
  • Epigastric
  • Anemia (hemorrhage)
  • Endoscopy
Acute pancreatitis
  • Nausea/vomiting
  • Sometimes improved with leaning forward
  • Upper abdominal pain
  • Radiating straight to the back
Dermatological
Shingles
  • Severe burning or throbbing pain
  • Dermatomal distribution
  • Maculopapular → vesicular rash in dermatomal distribution
Emotional/psychiatric condition
E.g., anxiety
  • Recent stress exposure
  • Severe left chest pain (where the heart is located)
  • Feelings of anxiety
  • Tachycardia
  • Retrosternal, variable
  • Negative workup for possible lethal causes
  • Diagnosis of exclusion

References:[1][2][2][3]

The differential diagnoses listed here are not exhaustive.

last updated 10/23/2018
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