Chest Pain Differential Diagnosis

History & Epidemiology

As a prevalent medical complaint, chest pain differential diagnosis often is needed. Chest pain has a wide range of causes, some of them life-threatening, and it accounts for 5% of all emergency hospital visits.1 It is most commonly caused by acute coronary syndrome, but chest pain also can be caused by factors including: gastrointestinal reflux disease (the most common non-cardiac cause of chest pain),2 pulmonary embolisms, pericarditis, and musculoskeletal factors.

Chest pain is reported in 7% to 24% of primary care visits,3 with the risk increasing after the age of 30. When a patient presents to a health care facility with chest pain, this chest pain should be triaged with a high priority level. An ECG should be administered to patients with suspected cardiac etiology of their chest pain, and the ECG results used to determine the necessary care plan.4

Chest Pain Risk Factors

There is a wide range of risk factors that can increase a patient’s risk of experiencing chest pain.

  • Risk factors for acute coronary syndrome can include a family history of cardiac disease, prior myocardial infarction, hypertension and/or hyperlipidemia, and diabetes.1
  • Pulmonary embolism risk factors include previous incidences of pulmonary embolism or deep vein thrombosis, use of hormonal medication, recent incidents of surgery, cancer, or an inability to walk.1
  • Other risk factors can include drug and tobacco use, recent endoscopies, bleeding disorders, or kidney disease.1

Prognosis

Chest pain can be life-threatening in some cases, but the prognosis will vary based on the cause. For acute coronary syndrome patients, the prognosis remains poor, despite many modern advancements in diagnosis and treatments. In patients whose chest pain symptoms were caused by myocardial infarction, research estimates that, within a year, 23% of women and 18% of men aged 40 and over will have died.5

For patients with non-cardiac chest pain, prognosis is good, with less severe effect on mortality. However, ongoing non-cardiac chest pain can decrease a person’s quality of life.2

Chest Pain Diagnosis & Presentation

If a patient presents with chest pain, it can often be difficult for them to describe it or identify its precise point of origin. This creates a challenge for medical professionals in chest pain diagnosis. If they can identify the source of the pain, health professionals should ask questions about the chest pain, including:

  • When the chest pain began
  • How long the chest pain has lasted
  • What the patient was doing when the chest pain began
  • If they can identify exactly where they feel the chest pain

For visceral pain, which is chest pain associated with internal organs, the pain tends to be described as deep, dull, and aching, and can also include vomiting and nausea. In contrast, somatic pain tends to be a stabbing, sharp pain that can be traced to one clear location in the body.6 Note that not every case presents with typical symptoms. Women and people with diabetes tend to have atypical symptoms or no symptoms of myocardial infarction.

The evaluation of the patient with chest pain should begin with a full physical examination. Clinicians should ask plenty of questions to get them to describe how the chest pain feels, as mentioned above. A chest pain physical exam should include the following:

  • A check of the patient’s general appearance and distress levels
  • Vital signs
  • Skin and neck exams
  • Chest, skin, heart, lung, and abdominal exams
  • A check of the limbs for swelling and calf pain

Patients should be asked about potential risk factors and have a thorough review of their medical history, including family history of cardiac disease and the patient’s history of tobacco and drug use.

When the patient presents with chest pain symptoms, it’s important to rule out life-threatening conditions like acute coronary syndrome. The patients with the highest risk of acute coronary syndrome may present with the following:

  • Male gender
  • Over the age of 60
  • Chest pain that feels like pressure and moves into the shoulder, arm, and/or neck

Once it’s determined the chest pain is not cardiac in origin, pleuritic or chest wall pain may also be considered. Pleuritic chest pain differential diagnosis often is identified by the following symptoms6:

  • Muscle tension localized to one part of the body
  • No coughing
  • Chest pain that’s described as ‘stinging’
  • Reproducibility on palpation

Chest Pain Workup & Chest Pain Physical Exam Findings

When diagnosing chest pain, there are many effective tools. When working out the causes of the chest pain, one effective tool is HEART, a chest pain differential diagnosis mnemonic. HEART7 was developed in the Netherlands in 2008 as a risk assessment tool for cardiac heart pain. HEART stands for:

  • H: History
  • E: Electrocardiogram (ECG)
  • A: Age
  • R: Risk factors
  • T: Troponin (Levels of troponin above 0.4 can indicate that the patient has experienced myocardial infarction.)

Each factor above corresponds to a numeric ranking, which is then added up and used to group patients into low, moderate, or high risk of life-threatening cardiac emergencies. Low-risk patients may be safe to discharge, while patients with higher risk levels may need further examination or urgent medical treatment.

Other diagnostic tools include:

  • Chest X-rays
  • Complete blood work
  • Computed tomography
  • Pulmonary angiography
  • Ultrasound

Chest Pain Differential Diagnosis

Due to the vague nature of chest pain, it can be representative of a wide range of medical conditions.8 Chest pain differential diagnosis can be broken down into categories:

  • Cardiac: acute coronary syndrome, pericarditis, congestive heart failure, post-cardiac injury syndrome
  • Hematologic: sickle cell anemia, pleural effusion
  • Gastrointestinal: pancreatitis, inflammatory bowel disease, bacterial pleurisy
  • Infections: abscesses to the liver, lung, or spleen, bacterial and viral infections

Other categories of chest pain differential diagnosis are iatrogenic, pulmonary, rheumatologic, and renal.

Once a thorough examination has been performed, medical professionals should be able to accurately diagnose the cause of the chest pain and recommend the appropriate treatment. If, after examination, the exact cause still can not be identified, the patient should be referred to a specialist for further testing.

References

1. Johnson, K, Ghassemzadeh, S. Chest Pain. In: StatPearls. NCBI Bookshelf version. StatPearls Publishing, 2022. Accessed September 6, 2022. https://www.ncbi.nlm.nih.gov/books/NBK470557/

2. Fass, R, Achem, S. Noncardiac Chest Pain: Epidemiology, Natural Course and Pathogenesis. J Neurogastroenterol Motil. 2011 Apr; 17(2): 110–123. doi: 10.5056/jnm.2011.17.2.110

3. Katerndahl, D. Chest Pain and Its Importance in Patients With Panic Disorder: An Updated Literature Review. Prim Care Companion J Clin Psychiatry. 2008; 10(5): 376–383. doi: 10.4088/pcc.v10n0505

4. Herren, K, Mackway-Jones, K. Emergency management of cardiac chest pain: a review. Emergency Medicine Journal.  2001;18:6-10.

5. Kolansky, D. Acute coronary syndromes: morbidity, mortality, and pharmacoeconomic burden. Am J Manag Care. 2009 Mar; 15(2 Suppl): S36-41.

6. Clarke, J. Introductory Chapter: The Patient Presenting with Chest Pain. Differential Diagnosis of Chest Pain. 2020. doi: 10.5772/intechopen.91925

7. Brady, W, de Souza, K. The HEART score: A guide to its application in the emergency department. Turk J Emerg Med. 2018 Jun; 18(2): 47–51. doi: 10.1016/j.tjem.2018.04.004

8. Reamy, B, Williams, P, Ryan, M. Pleuritic Chest Pain: Sorting Through the Differential Diagnosis. Am Fam Physician. 2017;96(5):306-312.

Author Bio

Katie Dundas is an American health writer currently based in Sydney, Australia. After moving overseas, she worked for seven years with the Prostate Cancer Foundation of Australia, managing health awareness and advocacy programs, and has been a freelance health writer for the last three years, with a focus on patient care.