Differential Diagnosis of Chest Pain

 Chest pain accounts for ~ six million annual visits to the ED

 Second most common complaint
 Causes
o Heart
o Aorta
o Lungs
o Esophagus
o Stomach
o Mediastinum
o Pleura
o Abdominal viscera

 Need to immediately recognize and rule out life threatening causes

o PAPPA-M

History

 Onset
o Abrupt vs gradual
 Location
o Substernal, chest wall, diffuse, localized
 Duration
o How long has it been there?
 Alleviating/Aggravating
 Radiation
o Shoulder, back, jaw
 Timing
o Constant vs episodic

 Prior diagnostic studies

 Is it similar to prior episodes/illnesses?
 Associated symptoms
o Nausea, vomiting, diaphoresis, dyspnea, syncope, palpitations, fever, peripheral edema

High risk symptoms:

 Exertional
 Pressure/tightness/aching
 Lasting hours
 Not reproducible
 Nausea & vomiting
 Shortness of breath
 Diaphoresis
  Radiating to jaw and/or arm

Low risk symptoms:

 Positional
 Pleuritic
 Sharp/stabbing
 Lasting seconds or minutes
 Reproducible

With that being said, nothing is 100%, and not every patient presents with text book symptoms. You must rule
out “PAPPA-M” before making a benign diagnosis. It is important to know the patient’s past medical history, social
history, family history, and risk factors.

All patients with chest pain need to have an EKG performed. An unremarkable EKG alone does not rule
out any cardiac event. A patient with a normal EKG may still be admitted to Observation in the hospital to rule out
an acute myocardial infarction.

 Comorbidities
o HTN
o DM
o PAD
o Malignancy
o Aortic valve abnormality
o Smoking history
o Age >55
o Male
o BMI >30
o Lifestyle (diet and exercise)
o Chronic kidney disease (CKD)
 Recent events
o Trauma
o Surgery/Procedure
o Periods of immobilization
 Other factors
o Cocaine use
o Tobacco use
o Family history

Life-threatening Conditions

 Pulmonary embolism
o 1 in 1,000
o Diagnosis is often missed
o Mortality rate based upon comorbidities and size of embolus
o Early diagnosis and treatment reduce mortality
 o Occurs when a dislodged venous clot migrates through the right side of the heart and becomes
lodged at the branch point of the pulmonary arteries (saddle emboli) or more distally
o Results in pulmonary hypertension, RV dysfunction, poor gas exchange, parenchymal infarction
 Acute coronary syndrome
o Leading killer of adults in developed countries
o < 15-30% of patients with non-traumatic chest pain have ACS
o Results from atherosclerotic plaque rupture and thrombus formation
o Coronary blood flow is reduced, and myocardial ischemia occurs
o The degree and duration of oxygen supply-demand mismatch determines whether the patient
develops unstable angina or myocardial infarction.

Stable angina is your pain on exertion???

 Pneumothorax
o Can occur following trauma or pulmonary procedures
o Can occur spontaneously
 Primary
 Without underlying lung disease
 Younger males who are tall and thin
 Secondary
 With underlying lung disease
 COPD, cystic fibrosis, asthma
o The accumulation of air in the pleural space can lead to tension pneumothorax with compression of
the mediastinum
 Pericardial tamponade
o Occurs when there is an accumulation of pericardial fluid under pressure
 Leads to impaired cardiac filling
o Varies from mild to severe
 May require emergent reduction in pericardial pressure by pericardiocentesis
o May occur with aortic dissection, after thoracic trauma, or from acute pericarditis
 Acute aortic dissection
o Most commonly affects patients with systemic hypertension in their 60’s
o May affect those with aortic valve or connective tissue abnormalities
o Typically begins with a tear in the inner layer of the aortic wall allowing blood to track between the
intima and media
o Pulsatile blood flow causes dissection with subsequent obstruction of branch arteries
 Mediastinitis
o Caused by odontogenic infections, esophageal perforation, and complications of cardiac surgery or
upper GI and airway procedures
o Spontaneous perforation (Boerhaave syndrome) results from sudden increase in intraesophageal
pressure usually caused by straining or vomiting
o Mortality 14-42%

Common Conditions

 Cardiac
o Acute congestive heart failure
  Chest discomfort, progressive dyspnea, cough, fatigue, and peripheral edema
o Stable angina
o Valvular heart disease
 Mitral valve prolapse, aortic stenosis
o Infectious/Inflammatory
 Pericarditis, myocarditis, endocarditis
 Pulmonary/Pleural
o Infectious
 Pneumonia, bronchitis
 Pleuritic chest pain with fever and cough
o Asthma
 Chest tightness and dyspnea
o Pulmonary malignancy
 Associated symptoms include cough, hemoptysis, dyspnea
o Pulmonary hypertension
 Exertional chest pain, dyspnea, and syncope
o Pleural effusion
o Pleuritis
 Inflammation of the lung pleura
 Caused by autoimmune disorders and drugs
 Associated symptoms include fever, rash, arthralgias
 Gastrointestinal
o Gastroesophageal reflux (GERD)
 Can mimic angina pectoris
 May be described as squeezing or burning, located substernally and radiating to the neck,
jaw, back, or arms
 It can last minutes to hours, and resolves spontaneously or with antacids
 May occur after meals, awaken patients from sleep, and be exacerbated by emotional
stress
o Esophageal spasm
o Sliding hiatal hernia
o Pancreatitis
 Epigastric pain
o Cholelithiasis
 RUQ abdominal pain, epigastric pain, substernal pain
 Occurs after meals
 Associated symptoms include nausea, vomiting, diarrhea
 Pain may radiate to right shoulder blade
 Musculoskeletal
o Rib contusion, rib fracture, intercostal muscle strain, costochondritis
o Reproducible on examination
o Most common is costochondritis
 Psychiatric
o Anxiety
 Other
o Herpes zoster, lupus, sarcoidosis, scleroderma
Pulmonary embolism

 Onset
o Sudden and severe; may worsen over time
 Pain quality
o Pain with deep inspiration or chest wall pain
 Location
 Associated symptoms
o Diaphoresis, nausea, shortness of breath, tachypnea, tachycardia, cough, syncope, hemoptysis
 Risk factors
o Prolonged immobilization, surgery, central venous catheterization, trauma, pregnancy,
malignancy, hypercoagulability, OCP
o Virchow’s Triad – conditions which predispose patients to developing blood clots
 Venous stasis – bedridden, long plane ride, immobilization
 Vessel damage – trauma, fractures, post-op
 Hypercoagulable states – cancer, high estrogen states, pregnancy
 Physical Examination
o Wheezing, asymmetric swelling
o Most common symptoms include dyspnea followed by pleuritic chest pain, cough, and symptoms
of a deep vein thrombosis
 Ancillary Studies
o EKG – sinus tachycardia, S1Q3T3
 Laboratory Studies
o D-dimer
 Sensitive not specific
 Imaging
o CXR
 Normal or Hampton’s hump
o CT, V/Q scan

Acute Coronary Syndrome

 Onset
o Gradual and worsens with exertion
 Pain quality
o Discomfort – pressure, heaviness, tightness, fullness, squeezing
o Ischemia is less likely if knifelike, sharp, pleuritic, positional
 Location
o Substernal or left chest
o Radiation to the arm, neck, jaw, back, abdomen, shoulders
 Associated symptoms
o Diaphoresis, nausea, vomiting
o Elderly – dyspnea, weakness, AMS, syncope
 Risk factors
o Male, >55 yo, FHx, DM, HLD, HTN, tobacco abuse
o Cocaine or amphetamine use
 Physical Examination
o Usually not helpful
 Ancillary Studies
 o EKG
 Laboratory Studies
o Troponin I and T
 Detect elevations within 3 hours, peak at 12 hours
 Remain elevated for 7-10 days
o CK-MB
 Rise to 2x normal at 6 hours and peak at 24 hours
 Imaging
o Nuclear stress test
 Prinzmetal angina – chest pain caused by vasospasm of the coronary artery
 Atypical presentations
o Females
o Elderly
o Diabetics

Pneumothorax

 Onset
o Sudden and severe
 Pain quality
o Sharp initially then dull and achy
 Location
o Ipsilateral chest pain
 Associated symptoms
o Shortness of breath
 Risk factors
o Tobacco abuse, HIV infected patient with pneumonia
 Physical Examination
o Unilateral decreased breath sounds
 Imaging
o Bedside ultrasound

Pericardial Tamponade from Pericarditis

 Inflammation of the pericardial sac

 Pleuritic chest pain that is improved by sitting up and leaning forward
 Etiologies include infection, medications, autoimmune disorders, and malignancy
 Diffuse ST segment elevation on EKG
 New or worsening pericardial effusion seen on echocardiogram
 Need to include an echocardiogram and ESR in your workup
 Beck’s triad
o Muffled heart sounds
o Pulsus paradoxus
 A condition in which a patient’s systolic blood pressure drops when they take a deep
breath
o Jugular venous distention (JVD)
 Treatment is usually NSAIDs
Acute aortic dissection

 Onset
o Sudden and severe
 Pain quality
o Sharp, severe
o Ripping, tearing
 Location
o Chest or back
o May radiate to chest, back, abdomen
 Associated symptoms
o Diaphoresis, nausea, syncope, voice hoarseness, AMS
 Risk factors
o Marfan’s syndrome, bicuspid aortic valve, cocaine use, pregnancy
 Physical Examination
o Discrepancies in pulse or blood pressure
 Imaging
o CXR
 Widened mediastinum or aortic knob
o CT, MRI, TEE
 Management
o Surgical vs medical management

o Consult Cardiothoracic surgery

 Type I

 Originates at the base of the aortic valve

 Dissects in the distal direction

 Requires immediate surgical intervention

 Type II

 Originates at the aortic arch

 Extends distally

 If it extends proximally to the aortic valve it will cause it to become incompetent

 New diastolic murmur

 More medically manageable than Type I

For test

Pappa M

High and low risk fact

Primary and second pnuemothorax

Virchow triad

Beck triad

Angina

Pulus paradoxus