20. The differential diagnostics and acute management of chest pain

Page created on April 9, 2022. Not updated since.

Introduction and epidemiology

Acute chest pain is a common cause of admission to the emergency department. Most cases are not life-threatening, but it’s important to rule out life-threatening causes.

Evaluation of chest pain

Everyone who is admitted with acute chest pain get:

  • Blood test checking for troponins, D-dimer, amylase, + other general tests
  • ECG

Further examinations are based on the examining physician’s differential diagnosis based on the patient’s clinical features. These may include:

  • Echocardiography
  • Imaging
  • Arterial blood gas

Life-threatening causes

Organ system Cause Typical features
Cardiac Acute coronary syndrome Heavy, dull, squeezing pain. Substernal pain with radiation to left shoulder. Nausea/vomiting. Sweating. Pain improves with nitroglycerine. Pathological ECG. Elevated troponins.
Aortic dissection Sudden onset, severe, sharp, tearing chest or abdominal pain that radiates to the back. Hypotension. Syncope. Asymmetric blood pressure between the arms.
Cardiac tamponade Hypotension. Jugular venous distension. Distant heart sounds. Tachypnoea. Dyspnoea. Pulsus paradoxus.
Chronic heart failure exacerbation Cough. Pulmonary crackles. Jugular venous distension. Peripheral oedema.
Takotsubo cardiomyopathy Recent stressful event. Acute heart failure.
Pulmonary Pulmonary embolism Acute onset. Pleuritic chest pain. Dyspnoea. Hypoxaemia. Cough. Haemoptysis. History of DVT or DVT risk factors. Obstructive shock if severe. ECG signs of right heart strain.
Tension pneumothorax Severe, sharp chest pain. Dyspnoea. Hypoxaemia. History of trauma. Hyperresonance on percussion. Decreased breathing sounds on auscultation.
Gastrointestinal Oesophageal perforation Retrosternal/neck/epigastric pain radiates to the back. Recent procedure near the oesophagus or severe emesis. Signs of sepsis. Vomiting. Subcutaneous emphysema.

Non-life-threatening causes

Organ system Cause Typical features
Cardiac Stable angina Retrosternal chest pain in relation to exercise, relieved with rest. Improves with nitroglycerine. Normal ECG and troponins.
Pericarditis Sharp retrosternal pain, worsens on inspiration, improves when leaning forward. Pericardial friction rub on auscultation.
Pulmonary Pneumonia Fever. Cough Ill appearance. Elevated inflammatory markers.
Asthma exacerbation Known asthma or recurrent episodes of dry cough and wheezing. Worsening of known symptoms. Dyspnoea. Tachypnoea. Hypoxaemia. Silent chest on auscultation. Hyperresonance on percussion.
COPD exacerbation Known COPD or known cough + dyspnoea. Worsening of known symptoms. Purulent sputum. Tachypnoea. Wheezing. Hypoxaemia, hypercapnia.
Gastrointestinal Gastroesophageal reflux disease Burning sensation substernally, aggravated in supinated position and after food. Epigastric tenderness.
Peptic ulcer disease Pain either relieved or worsened by food. Known risk factors.
Musculoskeletal Costochondritis Tenderness of the costochondral joint. Pain in the chest wall. Worsen with movement of the thorax, but not related to exercise.
Intercostal muscle strain Tenderness and pain in the intercostal muscles. Don’t worsen with exercise.
Other Anxiety attack Chest tightness. Palpitations. Tachypnoea. Diaphoresis. Anxious appearance.
Herpes zoster Burning pain. Maculopapular/vesicular rash on the chest.

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