Differential Diagnoses of CHEST PAIN

Differential Diagnoses of Patients Admitted to Hospital with Acute Chest Pain Ruled Not Myocardial Infarction

Diagnosis --------------------------------------------Percent

Gastroesophageal diseases ---------------------------42
----Gastroesophageal reflux
----Esophageal motility disorders
----Peptic ulcer
----Gallstones
Ischemic heart disease -------------------------------31

Chest wall syndromes-------------------------------- 28

Pericarditis -------------------------------------------4

Pleuritis/pneumonia ----------------------------------2

Pulmonary embolism ---------------------------------2

Lung cancer -----------------------------------------1.5

Aortic aneurysm --------------------------------------1

Aortic stenosis ----------------------------------------1

Herpes zoster -----------------------------------------1

having these symptoms?

1. Localized; sharp/stabbing or persistent/dull pain, reproduced by pressure over the painful area ----- this may mean Costochondralor chest wall pain.
2. Sharp pain, may be in radicular distribution; exacerbated by movement of neck, back---------this may mean Cervical or thoracic spine disease with nerve root compression.
3. Associated with dysphagia or gastric regurgitation; may be worsened by aspirin/alcohol ingestion/certain foods/supine position; often relieved by antacids----this may mean Esophageal or gastric pain.
4. Intolerance of fatty foods; right upper quadrant tenderness also present------this may mean Biliary pain.
5. Precipitated by exertion or emotional arousal; ECG (or Holter monitor) during pain shows ST segment shifts; pain relieved quickly ( <>------this may mean Myocardial ischemia.
   

chest pain? know more...

There is little correlation between the severity of chest pain and the seriousness
of its cause.
POTENTIALLY SERIOUS CAUSES

MYOCARDIAL ISCHEMIA Angina Pectoris Substernal pressure,
squeezing,constriction, with radiation typically to left arm; usually on exertion,
especially after meals or with emotional arousal. Characteristically relieved by
rest and nitroglycerin.
Acute Myocardial Infarction Similar to angina but usually
more severe,of longer duration (
30 min),and not immediately relieved by
rest or nitroglycerin. S3 and S4 common.
PULMONARY EMBOLISM May be substernal or lateral,
pleuritic in nature,and associated with hemoptysis, tachycardia, and
hypoxemia.
AORTIC DISSECTION Very severe,in center of chest, a
“ripping” quality,radiates to back, not affected by changes in position. May be
associated with weak or absent peripheral pulses.
MEDIASTINAL EMPHYSEMA Sharp,intense,localized to substernal
region; often associated with audible crepitus.
ACUTE PERICARDITIS Usually steady,crushing, substernal;
often has pleuritic component aggravated by cough,deep inspiration,
supine position,and relieved by sitting upright; one-, two-, or three-component
pericardial friction rub often audible.
PLEURISY Due to inflammation; less commonly tumor and pneumothorax.
Usually unilateral,knifelike,superficial, aggravated by cough and respiration.


LESS SERIOUS CAUSES

COSTOCHONDRAL PAIN In anterior chest,usually sharply localized,
may be brief and darting or a persistent dull ache. Can be reproduced by pressure
on costochondral and/or chondrosternal junctions. In Tietze’s syndrome (costochondritis),
joints are swollen,red, and tender.
CHEST WALL PAIN Due to strain of muscles or ligaments from excessive
exercise or rib fracture from trauma; accompanied by local tenderness.
ESOPHAGEAL PAIN Deep thoracic discomfort; may be accompanied
by dysphagia and regurgitation.
EMOTIONAL DISORDERS Prolonged ache or dartlike,brief,flashing
pain; associated with fatigue,emotional strain.

OTHER CAUSES
(1) Cervical disk; (2) osteoarthritis of cervical or thoracic spine; (3) abdominal
disorders: peptic ulcer,hiatus hernia, pancreatitis,biliary colic; (4) tracheobronchitis,
pneumonia; (5) diseases of the breast (inflammation, tumor); (6)
intercostal neuritis (herpes zoster).

Normal chest X-ray

Normal chest X-ray: posteroanterior projection. Note the heart is not enlarged (cardiothoracic ratio <50%) and the lung fields are clear. SVC, superior vena cava; RA, right atrium; AA, aortic arch; LV, left ventricle; PA, pulmonary artery; RV, right ventricle.

DIZZINESS AND SYNCOPE

Cardiovascular disorders produce dizziness and syncope by transient hypotension, resulting in abrupt cerebral hypoperfusion. Recovery is usually rapid, unlike with other common causes of syncope (e.g. stroke, epilepsy, overdose).

POSTURAL HYPOTENSION

Syncope on standing upright reflects inadequate baroreceptor-mediated vasoconstriction. It is common in the elderly. Abrupt reductions in blood pressure and cerebral perfusion cause the patient to fall to the ground, whereupon the condition corrects itself.

VASOVAGAL SYNCOPE

This is caused by autonomic overactivity, usually provoked by emotional or painful stimuli, less commonly by coughing or micturition. Only rarely are syncopal attacks so frequent as to be significantly disabling ('malignant' vasovagal syndrome). Vasodilatation and inappropriate slowing of the pulse combine to reduce blood pressure and cerebral perfusion. Recovery is rapid if the patient lies down.

CAROTID SINUS SYNCOPE

Exaggerated vagal discharge following external stimulation of the carotid sinus (e.g. from shaving, or a tight shirt collar) causes reflex vasodilatation and slowing of the pulse. These may combine to reduce blood pressure and cerebral perfusion in some elderly patients, causing loss of consciousness.

VALVULAR OBSTRUCTION

Fixed valvular obstruction in aortic stenosis may prevent a normal rise in cardiac output during exertion, such that the physiological vasodilatation that occurs in exercising muscle produces an abrupt reduction in blood pressure and cerebral perfusion, resulting in syncope. Vasodilator therapy may cause syncope by a similar mechanism. Intermittent obstruction of the mitral valve by left atrial tumours (usually myxoma) may also cause syncopal episodes.

STOKES-ADAMS ATTACKS These are caused by self-limiting episodes of asystole or rapid tachyarrhythmias (including ventricular fibrillation). The loss of cardiac output causes syncope and striking pallor. Following restoration of normal rhythm recovery is rapid and associated with flushing of the skin as flow through the dilated cutaneous bed is re-established.

PALPITATION

Awareness of the heartbeat is common during exertion or heightened emotion. Under other circumstances it may be indicative of an abnormal cardiac rhythm. A description of the rate and rhythm of the palpitation is essential. Extrasystoles are common but rarely signify important heart disease. They are usually experienced as 'missed' or 'dropped' beats; the forceful beats that follow may also be noticed. Rapid irregular palpitation is typical of atrial fibrillation. Rapid regular palpitation of abrupt onset occurs in atrial, junctional and ventricular tachyarrhythmias.

FATIGUE

Exertional fatigue is an important symptom of heart failure and is particularly troublesome towards the end of the day. It is caused partly by deconditioning and muscular atrophy but also by inadequate oxygen delivery to exercising muscle, reflecting impaired cardiac output.