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Differential diagnosis for chest pain

Common and important causes of chest pain for doctors and medical students

This refers to chest pain that is not sharp and is not the patient’s familiar angina. Ideally, the detailed history is taken where resuscitation facilities are available. Early, nonspecific ECG changes will suggest an acute coronary syndrome (ACS), a term that includes angina or infarction (MI) but serial ECG or troponin changes are usually needed to distinguish types of ACS:

  • Raised troponin indicates episode of muscle necrosis (remains elevated for up to two weeks). Normal troponin 12 hours after pain essentially rules out MI
  • ST-segment elevation indicates current ischaemia (or rarely ventricular aneurysm)

Further table of causes below:

Chest pain - acute or worsening

DiagnosisEvidence 
Angina (new or unstable)Suggested by: central pain ± radiating to jaw and either arm (left usually). Intermittent, brought on by exertion, relieved by rest or nitrates, and lasting <30 minutes. May be associated with transient ST depression or T inversions or, rarely, ST elevation.
Confirmed by: no troponin rise after 12 hours (excludes MI). Stress test showing inducible ischemia
ST-elevation myocardial infarction (STEMI)Suggested by: central chest pain ± radiating to jaw and either arm (left usually). Continuous, usually over 30 minutes, not relieved by rest or nitrates
Confirmed by: ST elevation 1 mm in limb leads or 2 mm in chest leads on serial ECGs (this is regarded as sufficient evidence to treat with thrombolysis). Raised troponin indicates episode of muscle necrosis up to 2 weeks before. Raised troponin may not be present in the first 4 hours after the onset of chest pain.
Non-ST elevation myocardial infarction (NSTEMI)Suggested by: central chest pain ± radiating to jaw and either arm (left usually). Continuous, usually over 30 minutes, not relieved by rest or nitrates
Confirmed by: elevated troponin after 12 hours. T-wave and ST-segment changes but no ST elevation on serial ECGs
Esophagitis and oesophageal spasmSuggested by: past episodes of pain when supine, after food. Relieved by antacids
Confirmed by: no increase in troponin after 12 hours and no ST-segment changes on ECG. Improvement with antacids. Esophagitis on endoscopy
Pulmonary embolus (arising from leg DVT, silent pelvic vein thrombosis, right atrial thrombus)Suggested by: central chest pain, also abrupt shortness of breath, cyanosis, tachycardia, loud second sound in pulmonary area, associated deep vein thrombosis, (DVT) or risk factors such as cancer, recent surgery, immobility
Confirmed by: V/Q scan with mismatched ventilation and perfusion, spiral (helical) CT (CT-pulmonary angiogram) showing clot in pulmonary artery
PneumothoraxSuggested by: abrupt pain in center or side of chest with abrupt breathlessness. Resonance to percussion over site
Confirmed by: expiration CXR showing dark field with loss of lung markings outside sharp line containing lung tissue
Dissecting thoracic aortic aneurysmSuggested by: ‘tearing pain often radiating to back and not responsive to analgesia, abnormal or absent peripheral pulses, early diastolic murmur, low blood pressure, and wide mediastinum on CXR
Confirmed by: loss of single clear lumen on CT scan or MRI
Chest wall pain (e.g.costochondritis and Tietze’s syndrome, strained muscle or rib injury)Suggested by: chest pain and localized tenderness of chest wall or chest pain on twisting of neck or thoracic cage
Confirmed by: no rise in troponin after 12 hours, and no ST-segment changes or T-wave changes serially on ECG. Response to rest and analgesics

Related page: pleuritic chest pain

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