CONTENTS
- Preamble
- Differential diagnosis
- [1] Chest pain history
- [2] Pretest probability for four critical diagnoses
- [3] Bedside examination with POCUS
- [4] Immediate bedside tests
- [5] Laboratory testing & advanced imaging
- Questions & discussion
- Chest pain is a common symptom that will be encountered in any clinical venue (e.g., outpatient medicine, emergency department, intensive care unit).
- The appropriate intensity of evaluation depends on the clinical context. For example, a young patient with fleeting twinges of chest pain doesn't require an exhaustive evaluation. Alternatively, a patient with ongoing chest pain following percutaneous coronary intervention or cardiothoracic surgery will require a more nuanced evaluation.
- This chapter presents the fundamental differential diagnosis, historical features, and diagnostic tests that may be utilized to investigate chest pain. These fundamentals need to be adapted to your specific clinical context (e.g., a validated chest pain protocol for use in the emergency department may be extremely useful).
cardiac
- Myocardial ischemia (including unstable angina).
- Aortic dissection (or other acute aortic syndromes).
- Pericarditis.
- Myocarditis.
- Takotsubo cardiomyopathy.
pulmonary
- PE.
- Pneumothorax.
- Pneumonia.
- Pleuritis (e.g., connective tissue disease, viral infection, uremic).
- Pulmonary hypertension (may cause anginal-quality pain with exertion).
- Lung cancer.
gastrointestinal
- GERD (gastroesophageal reflux disorder).
- Esophageal spasm.
- Esophagitis.
- Esophageal rupture with mediastinitis.
- Cholecystitis.
- Peptic ulcer disease.
- Pancreatitis.
neurologic
- Herpes zoster.
- Cervical root compression.
- Thoracic outlet syndrome.
musculoskeletal & rheumatologic
- Costochondritis.
- Rib fracture or other trauma.
- Intercostal muscle strain.
- Sternoclavicular arthritis.
psychiatric
- Anxiety.
- Somatization/functional disorders.
[1] location & radiation
- Location:
- Migration over time suggests aortic dissection.
- Very focal pain suggests chest wall or pleural source (rather than visceral pain). (Griffin 2022)
- Dermatomal distribution may suggest Herpes zoster.
- Radiation:
- Ischemia: may radiate to arms, neck, jaw, teeth, lower face, or epigastrium.
- Dissection: often radiates to the back.
- Pericarditis: may radiate to neck, back, trapezius ridge.
- Musculoskeletal pain shouldn't radiate.
[2] timing & patterning
- Rapid onset of pain?
- Ischemia: often takes a few minutes to reach maximal severity.
- Sudden/instantaneous onset:
- Aortic dissection.
- Pneumothorax and/or pneumomediastinum.
- PE (pain may reflect distension of the pulmonary artery). (Braunwald 12e)
- Duration of pain?
- Fleeting chest pain (lasting seconds) is rarely ischemic.
- Angina may last 2-10 minutes.
- Acute myocardial infarction usually lasts >30 minutes.
- Recurrent episodes of chest pain may suggest:
- Myocardial ischemia (anginal episodes).
- Gastroesophageal reflux disease.
- Esophageal spasm.
[3] palliating or provoking factors?
- Palliating factors?
- Sitting and leaning forward may alleviate pericarditis or GERD.
- Nitroglycerine seems to improve pain:
- Caution: Diagnostic performance is poor.
- May suggest the following possibilities:
- Myocardial ischemia.
- Esophageal spasm.
- Random chance; placebo effect.
- Provoking factors?
- Exertional: suggests ischemia.
- Swallowing triggers pain: esophageal pathology (including esophageal perforation).
- Inspiration (pleuritic chest pain is worse with inspiration, but not general movement/palpation). Causes include:
- Pneumothorax.
- PE.
- Pericarditis.
- Pleuritis, pleuropericarditis.
- Mediastinitis, pneumomediastinum.
- Pneumonia.
- Esophageal disease.
- Musculoskeletal (e.g., costochondritis).
[4] associated symptoms
- Diaphoresis? (worrisome in general, including ischemia)
- Nausea/vomiting?
- Nausea/vomiting simultaneous with pain concerning for ischemia.
- Retching with subsequent pain suggests esophageal rupture (Boerhaave syndrome).
- Dyspnea? (MI, PE, pulmonary pathology, pneumothorax).
- Neurologic symptoms? (may suggest aortic dissection).
- Leg pain/swelling? (may suggest pulmonary embolism).
- Viral prodrome? (pericarditis, myocarditis, pneumonia, costochondritis, MI).
There are many life-threatening entities on the differential diagnosis of chest pain. However four in particular should be borne in mind since these are immediately life-threatening and may be easily missed on an initial evaluation (as opposed to, say, pneumothorax – which is life-threatening but unlikely to be missed).
[1/4] MI
- Risk factors include:
- Personal history of atherosclerotic disease (e.g., prior MI, peripheral artery disease).
- Age.
- Smoking.
- Diabetes, hypertension.
- Radiation therapy.
- Sympathomimetic use (cocaine/methamphetamine).
- Vasculitis.
- Likelihood ratio for pain attributes: (16304077)
- Radiation to arm(s) or shoulder(s): LR ~4.
- Worse with exertion: LR ~2.5
- Associated with diaphoresis: LR ~2.
- Sharp: LR ~0.3
- Positional: LR ~0.3
- Reproducible with palpation: LR ~0.3
- Pleuritic: LR ~0.2
- ⚠️ Caution: chest pain may be atypical in women, elderly, or patients with diabetes.
[2/4] PE
- Risk factors:
- Recent surgical procedures (especially orthopedic).
- Recent hospitalization for heart failure or MI.
- Prior venous thromboembolic disease.
- Malignancy (especially metastatic).
- Postpartum (especially after C-section).
- Estrogen-containing oral contraceptives, hormone replacement therapy, in vitro fertilization.
- Older age.
- Immobility.
- Thrombophilia (including autoimmune diseases, inflammatory bowel disease, infection).
- Approach to PE diagnosis: 📖
[3/4] aortic dissection
- Risk factors:
- Hypertension.
- Older age.
- Connective tissue disorder (e.g., Marfan syndrome).
- Known aortic pathology (e.g., bicuspid valve, coarctation).
- Sympathomimetic use (cocaine, methamphetamine).
- A recent procedure involving the aorta.
- Pregnancy (especially 3rd trimester).
- Clinical approach to evaluate dissection (including dissection risk score): 📖
[4/4] esophageal rupture
- Risk factors:
- Severe retching/vomiting followed by chest pain.
- History of prior esophageal disease.
- History of recent esophageal procedures (e.g., nasogastric tube, Blakemore tube, endoscopy).
- Further discussion of evaluation for esophageal rupture here: 📖
general physical examination including
- Vital sign abnormalities, e.g.:
- Hypoxemia suggests pleural or pulmonary pathology.
- Shock index (HR/SBP) >~0.8 is very worrisome (e.g., tension pneumothorax, pericardial tamponade, pulmonary embolism, cardiogenic shock).
- Marked hypertension may suggest aortic dissection or a primary hypertensive emergency with secondary demand ischemia.
- Blood pressure in both arms (differential may occur in aortic dissection).
- Pericardial friction rub?
- Abdominal palpation (cholecystitis or peptic ulcer disease may radiate to the chest).
- Skin exam: look for herpes zoster.
- Evidence of lower extremity DVT (e.g., swelling, tenderness).
cardiac POCUS including
- ? Reduced EF or wall motion abnormalities (ischemia, myocarditis).
- ? Pericardial effusion (pericarditis, aortic dissection).
- ? Right ventricular dilation, clot-in-transit (? PE).
- ? Signs of aortic dissection (aortic regurgitation, aortic dilation, dissection flap in ascending or descending aorta).
pulmonary POCUS including
- ? Pneumothorax.
- ? Pleural effusions (may reveal pleuritis; POCUS has higher sensitivity than chest radiograph).
DVT POCUS
- If there is concern for PE, perform a screening evaluation of femoral and popliteal veins for DVT. This will only be ~30-40% sensitive for PE, but it may rapidly yield a diagnosis if positive.
ECG
- ECG should be immediately obtained for all patients with chest pain.
- If abnormal or concern for ischemia: repeat after 15-20 minutes.
- Diagnoses that often cause EKG abnormalities include:
- Myocardial ischemia.
- Pulmonary embolism.
- Pericarditis, myocarditis, or myopericarditis.
- Takotsubo cardiomyopathy.
chest radiograph
- ? Mediastinal widening (consider aortic dissection, but limited performance).
- ? Pneumothorax.
- ? Pleural effusion.
- ? Parenchymal lung pathology (e.g., pneumonia, malignancy).
- ? Skeletal abnormality (e.g., rib fracture, spinal compression fracture).
Ideally, laboratory and advanced imaging studies will be selected in a focused manner (depending on history, physical examination, and immediate bedside tests).
laboratory studies to consider
- Electrolytes.
- Complete blood count with differential.
- Troponin (if concern for ischemia).
- D-dimer:
- Pregnancy test as appropriate.
- Liver function tests (if examination and history suggest biliary pathology).
formal echocardiogram
- It may help evaluate for ischemia, myocarditis, pericarditis, or Takotsubo cardiomyopathy.
- STAT echo may be available at some hospitals (especially during daylight hours).
- Echocardiography is especially helpful in the following situations:
- EKG is abnormal and concerning for occlusive myocardial infarction (e.g., myocardial infarction vs. pericarditis).
- POCUS suggests an echocardiographic abnormality, but the results are unclear.
- Echocardiography may be less useful in:
- Patients with a known prior myocardial infarction or cardiomyopathy (it may be difficult to differentiate acute from chronic pathology).
- Patients with a normal EKG.
CT scan indications may include:
- CT angiography to evaluate for PE (if indicated by the PE algorithm below; further discussion about PE diagnosis here: 📖).
- CT angiography to evaluate for aortic dissection.
- CT to evaluate for esophageal perforation.
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References
- Gaggin, H. K., & Januzzi, J. L., Jr. (2021). MGH Cardiology Board Review. Springer Science & Business Media.
- Griffin BP, Kapadia SR, and Menon V. The Cleveland Clinic Cardiology Board Review. (2022). Lippincott Williams & Wilkins.
- Libby, P. (2022). Braunwald’s Heart Disease – E-Book: A Textbook of Cardiovascular Medicine. Elsevier Health Sciences.
- Sadhu, J., Husaini, M., & Williams, D. (2023). The Washington Manual Cardiology Subspecialty Consult. Lippincott Williams & Wilkins.