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.

PAROXYSMAL NOCTURNAL DYSPNOEA

Frank pulmonary oedema on lying flat wakes the patient from sleep with distressing dyspnoea and fear of imminent death. The symptoms are corrected by standing upright, which allows gravitational pooling of blood to lower the left atrial pressure, the patient often feeling the need to obtain air at an open window.

ORTHOPNOEA

In patients with heart failure lying flat causes a steep rise in left atrial pressure, resulting in pulmonary congestion and severe dyspnoea. To obtain uninterrupted sleep extra pillows are required, and in advanced disease the patient may choose to sleep sitting in a chair.

EXERTIONAL DYSPNOEA

This is the most troublesome symptom in heart failure. Exercise causes a sharp increase in left atrial pressure and this contributes to the pathogenesis of dyspnoea by causing pulmonary congestion (see above). However, the severity of dyspnoea does not correlate closely with exertional left atrial pressure, and other factors must therefore be important. These include respiratory muscle fatigue and the effects of exertional acidosis on peripheral chemoreceptors. As left heart failure worsens, exercise tolerance deteriorates. In advanced disease the patient is dyspnoeic at rest.

DYSPNOEA

Dyspnoea is an abnormal awareness of breathing occurring either at rest or at an unexpectedly low level of exertion. It is a major symptom of many cardiac disorders, particularly left heart failure, but its mechanisms are complex. In acute pulmonary oedema and orthopnoea, dyspnoea is due mainly to the elevated left atrial pressure that characterizes left heart failure. This produces a corresponding elevation of the pulmonary capillary pressure and increases transudation into the lungs, which become oedematous and stiff. The extra effort required to ventilate the stiff lungs causes dyspnoea. In exertional dyspnoea, however, other mechanisms apart from changes in left atrial pressure are also important.

Acute LVF

Typical patient
• Patient with acute myocardial infarction or known left ventricular disease

Major symptoms
• Severe dyspnoea and variable circulatory collapse

Major signs
• Low-output state (hypotension, oliguria, cold periphery); tachycardia; S3; sweating; crackles at lung bases

Diagnosis
• CXR: bilateral air space consolidation with typical perihilar distribution
• Echocardiogram: usually confirms left ventricular disease

Additional investigations
• ECG: may show evidence of acute or previous myocardial infarction
• Blood gas analysis: shows variable hypoxaemia

Comments
• Although most cases are caused by acute myocardial infarction or advanced left ventricular disease, it is vital to exclude valvular disease or myxoma, which are potentially correctable by surgery.

Aortic dissection

Typical patient
• Middle-aged or elderly patient with a history of hypertension or arteriosclerotic disease
• Occasionally younger patient with aortic root disease (e.g. Marfan's syndrome)

Major symptoms
• Chest pain

Major signs
• Often none
• Sometimes regional arterial insufficiency (e.g. occlusions of coronary artery causing myocardial infarction, carotid or verterbral artery causing stroke, spinal artery causing hemi- or quadriplegia); subclavian artery occlusion may cause differential blood pressure in either arm; aortic regurgitation; cardiac tamponade; sudden death

Diagnosis
• CXR: widened mediastinum, occasionally with left pleural effusion
• Transoesophageal echocardiogram: confirms dissection
• CT scan: confirms dissection
• MRI scan: confirms dissection

Additional investigations
• None

Comments
• Having estabished the diagnosis, emergency surgery is usually necessary, particularly if the dissection involves the ascending thoracic aorta

Causes of acute pericarditis

• Idiopathic
• Infective
• viral (Coxsackie B, influenza, herpes simplex)
• bacterial (Staphylococcus aureus, Mycobacterium tuberculosis)
• Connective tissue disease
• systemic lupus erythematosus
• rheumatoid arthritis
• polyarteritis nodosa
• Uraemia
• Malignancy (e.g. breast, lung, lymphoma, leukaemia)
• Radiation therapy
• Acute myocardial infarction
• Post myocardial infarction/cardiotomy (Dressler's syndrome)

Acute myocardial infarction

Typical patient
• Middle-aged (male) or elderly (either sex), often with a family history of coronary heart disease and one or more of the major reversible risk factors (smoking, hypertension, hypercholesterolaemia)
• In many patients there is no preceding history of angina

Major symptoms
• Chest pain and shortness of breath. Pain usually prolonged and often described as 'heaviness' or 'tightness', with radiation into arms, neck or jaw. Alternative descriptions include 'congestion' or 'burning', which may be confused with indigestion

Major signs
• Ischaemic myocardial damage, fourth heart sound, dyskinetic precordial impulse
• Autonomic disturbance, tachycardia (anterior MI), bradycardia (inferior MI), sweating, vomiting, syncope

Diagnosis
• Markers of injury: raised CKMB and troponins
• ECG: may be normal or show ST depression or T-wave change (non-ST elevation myocardial infarction). ST elevation myocardial infarction denotes higher risk

Additional investigations
• Biochemistry: blood sugar and lipids to rule out diabetes and dyslipidaemia
• Risk stratification: echocardiogram (LV function) and stress testing (reversible ischaemia)

Comments
• History and troponin testing most useful diagnostic tools

Rare cardiovascular causes of chest pain include mitral valve disease associated with massive left atrial dilatation. This causes discomfort in the back, sometimes associated with dysphagia due to oesophageal compression. Aortic aneurysms can also cause pain in the chest owing to local compression.

Causes of coronary artery disease

• Atherosclerosis
• Arteritis
• systemic lupus erythematosus
• polyarteritis nodosa
• rheumatoid arthritis
• ankylosing spondylitis
• syphilis
• Takayasu's disease
• Embolism
• infective endocarditis
• left atrial/ventricular thrombus
• left atrial/ventricular tumour
• prosthetic valve thrombus
• complication of cardiac catheterization
• Coronary mural thickening
• amyloidosis
• radiation therapy
• Hurler's disease
• pseudoxanthoma elasticum
• Other causes of coronary luminal narrowing
• aortic dissection
• coronary spasm
• Congenital coronary artery disease
• anomalous origin from pulmonary artery
• arteriovenous fistula

This also causes central chest pain, which is sharp in character and aggravated by deep inspiration, cough or postural changes. It is usually idiopathic or caused by Coxsackie B infection. It may also occur as a complication of myocardial infarction, but other causes are seen less commonly

Causes of angina

Impaired myocardial oxygen supply
• Coronary artery disease
• atherosclerosis
• arteritis in connective tissue disorders
• diabetes mellitus
• Coronary artery spasm
• Congenital coronary artery disease
• arteriovenous fistula
• anomalous origin from pulmonary artery
• Severe anaemia

Increased myocardial oxygen demand
• Left ventricular hypertrophy
• hypertension
• aortic valve disease
• hypertrophic cardiomyopathy
• Tachyarrhythmias

Angina

Typical patient
• Middle-aged or elderly man or woman often with a family history of coronary heart disease and one or more of the major reversible risk factors (smoking, hypertension, hypercholesterolaemia)

Major symptoms
• Exertional chest pain and shortness of breath. Pain often described as 'heaviness' or 'tightness', and may radiate into arms, neck or jaw

Major signs
• None, although hypertension and signs of hyperlipidaemia (xanthelasmata, xanthomas) may be present
• Peripheral vascular disease, evidenced by absent pulses or arterial bruits, is commonly associated with coronary heart disease

Diagnosis
• Typical history is most important diagnostic tool
• ECG: often normal; may show Q waves in patients with previous myocardial infarction
• Stress test: exertional ST depression
• Isotope perfusion scan: exertional perfusion defects
• Coronary arteriogram: confirms coronary artery disease

Additional investigations
• Blood sugar and lipids to rule out diabetes and dyslipidaemia

Comments
• A careful history is the single most important means of diagnosing angina

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