chest pain differential diagnosis

3 min read 12-03-2025

Chest pain is a common complaint with a wide range of potential causes, from benign to life-threatening. Accurate diagnosis is crucial, as the underlying condition dictates the appropriate management. This article provides a comprehensive overview of the differential diagnosis of chest pain, emphasizing the importance of thorough history-taking and physical examination. Understanding chest pain requires considering its location, character, radiation, associated symptoms, and risk factors.

Categorizing Chest Pain: A Systematic Approach

To effectively diagnose chest pain, it's helpful to categorize it based on its likely origin:

1. Cardiac Causes:

Acute Coronary Syndrome (ACS): This encompasses unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). ACS presents with chest pressure, tightness, or pain often radiating to the arm, jaw, or back. Symptoms may include shortness of breath, diaphoresis, and nausea. ECG and cardiac biomarkers are crucial for diagnosis. This is a medical emergency.
Pericarditis: Inflammation of the pericardium causes sharp, stabbing chest pain that worsens with deep breaths or lying down. A pericardial friction rub may be audible on auscultation. ECG changes are often present.
Aortic Dissection: A tear in the aorta causes sudden, severe tearing pain radiating to the back. This is a life-threatening emergency requiring immediate intervention. Diagnosis is often made with CT angiography.
Myocarditis: Inflammation of the heart muscle can present with chest pain, shortness of breath, and palpitations. Diagnosis involves ECG, cardiac biomarkers, and possibly cardiac MRI.

2. Pulmonary Causes:

Pulmonary Embolism (PE): A blood clot in the lung can cause sudden onset chest pain, shortness of breath, and sometimes coughing up blood. Diagnosis often requires imaging studies like CT pulmonary angiography or ventilation-perfusion scan. This is a serious condition requiring prompt medical attention.
Pneumothorax: Collapsed lung causes sudden, sharp chest pain, shortness of breath, and decreased breath sounds on the affected side. Chest X-ray confirms the diagnosis.
Pneumonia: Infection of the lungs can cause chest pain, cough, fever, and shortness of breath. Diagnosis involves chest X-ray and sometimes blood tests.
Pleuritis (Pleurisy): Inflammation of the pleura (lining of the lungs) causes sharp, stabbing chest pain that worsens with deep breaths or coughing. A pleural friction rub may be audible.

3. Musculoskeletal Causes:

Costochondritis: Inflammation of the cartilage connecting the ribs to the breastbone causes localized chest pain, often worsened by movement or palpation.
Rib Fracture: A broken rib causes sharp, localized pain, worsened by breathing or movement.
Muscle Strain: Overexertion of chest muscles can cause chest pain and tenderness.

4. Gastrointestinal Causes:

Gastroesophageal Reflux Disease (GERD): Stomach acid refluxing into the esophagus can cause burning chest pain (heartburn), often relieved by antacids.
Esophageal Spasm: Sudden, intense chest pain that may mimic angina.
Peptic Ulcer Disease: A sore in the lining of the stomach or duodenum can cause epigastric pain, sometimes radiating to the chest.

5. Other Causes:

Anxiety/Panic Attacks: Chest pain, palpitations, shortness of breath, and dizziness are common symptoms.
Herpes Zoster (Shingles): Painful rash along a dermatome, potentially involving the chest.
Tumors: Lung, esophageal, or breast cancers can cause chest pain, depending on their location and size.

When to Seek Immediate Medical Attention

Chest pain requiring immediate medical attention includes:

Sudden onset, severe chest pain: Especially if radiating to the arm, jaw, or back.
Chest pain accompanied by shortness of breath, diaphoresis, or nausea.
Chest pain with lightheadedness or syncope.
Tearing chest pain.

Diagnostic Workup

The evaluation of chest pain typically involves:

Detailed history and physical examination: This is crucial in guiding further investigations.
Electrocardiogram (ECG): Detects cardiac rhythm abnormalities and signs of myocardial ischemia or infarction.
Cardiac biomarkers: Troponin levels help assess for myocardial damage.
Chest X-ray: Evaluates the lungs and heart.
Echocardiogram: Assesses heart structure and function.
CT scan: May be used to evaluate for pulmonary embolism, aortic dissection, or other conditions.
Other tests: May include stress testing, coronary angiography, esophageal endoscopy, or other specialized studies based on clinical suspicion.

Conclusion

Chest pain presents a diagnostic challenge due to its diverse etiology. A systematic approach, including a thorough history, physical examination, and appropriate investigations, is crucial for accurate diagnosis and timely management. The prompt recognition of life-threatening conditions such as ACS and aortic dissection is paramount to ensuring optimal patient outcomes. Always seek medical attention if you experience concerning chest pain. Remember, this information is for educational purposes and should not replace professional medical advice. Consult a physician for any health concerns.