CHEST PAIN
DIFFERENTIAL DIAGNOSIS
Walid TARCHA,MD
UMC RIZK HOSPITAL
Chest Pain Differential
• Angina • Esophageal
reflux/spasm
• Pericarditis • Peptic/biliary/colonic
• Pleurisy referred pain
• Pulmonary • Chest wall pain
Embolism • Neurogenic pain
– C disc disease
• Aortic dissection – Thoracic outlet
– shingles
Differential Diagnoses
Acute myocardial infarction, Acute coronary ischemia, Aortic dissection, Cardiac
Cardiovascular tamponade, Unstable angina, Coronary spasm, Prinzmetal's angina, Cocaine
induced, Pericarditis, Myocarditis, Valvular heart disease, Aortic stenosis, Mitral
valve prolapse, Hypertrophic cardiomyopathy
Pulmonary embolus, Tension pneumothorax, Pneumothorax, Mediastinitis,
Pulmonary Pneumonia, Pleuritis, Tumor, Pneumomediastinum
Esophageal rupture (Boerhaave), Esophageal tear (Mallory-
Gastrointestinal Weiss), Cholecystitis, Pancreatitis, Esophageal spasm, Esophageal
reflux, Peptic ulcer, Biliary colic
Muscle strain, Rib fracture, Arthritis, Tumor, Costochondritis, Nonspecific chest
Musculoskeletal wall pain
Spinal root compression, Thoracic outlet, Herpes zoster, Postherpetic neuralgia
Neurologic
Psychologic, Hyperventilation
Other
Causes Table 49-1
2. Pleuritic
1. Chest wall
• Pulmonary Embolism
• Costosternal synd
• Pneumonia
• Costochrondritis
• Spontaneous pneumo
• Precordial catch synd
• Pericarditis
• Slipping Rib Synd
• Pleurisy
• Xiphodynia
• Radicular Synd
• Intercostal Nerve
• Fibromyalgia
Categorizing Chest Pain
Assessment of Risk Factors
• Aortic Dissection:
– Middle Aged
– Male
– Hypertension
– Marfan Syndrome
Differential Dx ACS
• Aortic Dissection:
– Risk Factors – Atherosclerosis, HTN (uncontrolled),
Coarctation of Aorta, Bicuspid Aortic Valve, Aortic
Stenosis, Marfan Syn, Ehlers-Danlos Syn, Pregnancy
– Pain – midline Substernal CP, tearing, ripping,
searing, radiating to interscapular area
– Pain Above AND Below Diaphragm
– Often assoc. with stroke, AMI, limb ischemia
AORTIC DISSECTION
• WIDENED
MEDIASTINUM
Categorizing Chest Pain
Assessment of Risk Factors
• Pulmonary Embolism
– Hypercoagulable Diathesis
– Malignancy
– Recent Immobilization
– Recent Surgery
Differential Dx ACS
• Pulmonary Embolism:
– Atypical, presenting with any combination of:
• Chest Pain, Dyspnea, Syncope, Shock, Hypoxia
• Fever, cough, hemoptosis
– Pain is often pleural
• Reproducible with breathing, palpation
– Classic presentaion:
• Sharp pain, Dyspnea
• Tachypnea, tachycardia, hypoxemia
PE: DIAGNOSTIC TESTS
• ABG:
*Look for abnormal PaO2 or A-a gradient
• D Dimer:
*Often elevated in PE.
* Useful test in low probability patients.
*May be abnormally high in various conditions:
(Malignancy, Pregnancy, sepsis, recent surgery)
Pulmonary Embolism – Diagnostic Imaging Algorithm
Differential Dx ACS
• Spontaneous Pneumothorax:
– Risks:
• Sudden Change in barometric pressure
• Smokers, COPD, Idiopathic Bleb DZ
– Pain:
• sudden, sharp, pleuritic chest pain, and dyspnea
– Dx:
• Absence of breath sounds ipsilaterally
• Hyper resonance to percussion
• CXR – Dx simple pneumo
TENSION PNEUMOTHORAX
• Answer: Chest Xray
should have never
been obtained
• Tension PTX is a
clinical diagnosis
requiring immediate
life saving measures
Differential Dx ACS
• Esophageal Rupture (Boerhaave Syn):
– Life-threatening
– Substernal, sharp CP
– Sudden onset after forceful vomiting
– Dyspneic, diaphoretic, and ill-appearing
– CXR: Normal, SQ air, Pleural Effusions,
Pneumothorax, pneumoperitoneum,
pneumomediastinum
– Water Soluble Contrast Study
Differential Dx ACS
• Acute Pericarditis:
– Acute, sharp, severe, constant, substernal CP
– Radiation to back, neck, shoulders
– Worse with lying down and inspiration
– Relief with leaning forward
– FRICTION RUB
– EKG: ST segment elev., T wave inversion, or
PR depression
ACUTE PERICARDITIS
• COMMON CAUSES
* IDIOPATHIC
* INFECTIOUS
* MALIGNANCY
* UREMIA
* RADIATION INDUCED
* POST MI (DRESSLER SYNDROME)
* MYXEDEMA
* DRUG INDUCED
* SYSTEMIC RHEUMATIC DISEASES
2. SSFP Cine
Pericardial Effusion
Effusive Constrictive Pericarditis
• Obtain steady state free precession
(SSFP) cine images in two, three, and four
chamber cardiac orientations.
• Above are four chamber SSFP cine views
of representative pericardial disorders. Pericardial Constriction
Differential Dx ACS
• Pneumonia:
– Sharp and Pleuritic
– Fever, cough, hypoxia
– Rales, decreased breath sounds, etc.
– CXR
RUL PNEUMONIA
• RUL INFILTRATE
LOCALIZING THE INFILTRATE
Differential Dx ACS
• Musculoskeletal/Chest Wall Disorders:
– LOCALIZED, Sharp, positional CP
– Reproducible
– Types –
• Costochondritis, Tietze Syndrome
• Xiphodynia
DDx: CHEST PAIN
• CHEST WALL PAIN
-Skin and sensory nerves
-Herpes Zoster
- Musculoskeletal system
- Isolated Musculoskeletal Chest Pain Syndrome
*Costochondritis
*Xiphoidalgia
*Precordial Catch Syndrome
*Rib Fractures
- Rheumatic and Systemic Diseases causing
chest wall pain
CHEST WALL PAIN
• HERPES ZOSTER
-Reactivation of Herpes Varicellae
- Immunocompromised patients often
at risk for reactivation.
- 60% of zoster infections involve the trunk
- Pain may precede rash
HERPES ZOSTER
• Clusters of vesicles (with
clear or purulent fluid)
grouped on an
erythematous base.
Lesions eventually
rupture and crust.
• Dermatomal distribution.
• Usually unilateral
involvement that halts at
midline
Differential Dx ACS
• GI Disorders: GERD/dyspepsia
– burning, gnawing low CP
– Acidic taste
– Recumbent position increases pain
– Relief per antacids
• CAREFUL, can also help in ACS
Differential Dx ACS
• Panic Disorder:
– Recurrent, Unexpected panic
– Including at least 4 SX:
• Palpitations, diaphoresis, tremor, dyspnea,
choking, CP, nausea, dizziness, derealization, or
depersonalization, fear of losing control or dying,
paresthesias, chills, hot flashes
– Rule out substance abuse
• Stable angina
– Angina brought on by exertion and relieved
with predictable measures (rest, NTG)
• Unstable angina/ACS
– New onset angina w/i past 2/12 and at least
CCS III
– Rest angina lasting >20 min & presenting w/i
one week of angina
– Change from baseline
Pathophysiology of Stable and
Unstable Plaques
Thin fibrous cap
Thrombus
Thick fibrous cap
Smooth muscle
cells
Lipid rich core
and
macrophages
Media
Unstable Stable plaque
plaque
Continuing Medical
Implementation
Terminology
• Acute Coronary Syndromes is the preferred
terminology to refer a spectrum of disease related to
myocardial ischemia
+/- abN ECG,
(stable angina)
-ve markers
+/- abN ECG, Unstable Angina
+ve markers
NSTEMI
STE on ECG,
+ve markers
STEMI
Non ST Elevation MI
Ruptured Plaque
90% of acute MIs are caused by thrombus formation from rupture of unstable
Continuing
plaquesMedical
Implementation
Occlusive Thrombus
Continuing Medical
Implementation
GUSTO 2B: ST Depression
A High-Risk Patient Population
10% T-wave inversion
ST-segment depression ST
8% ST-segment elevation
P 0.001
ST
Mortality
6%
4%
T-wave
2% inversio
n
0%
0 30 60 90 120 150 180
Days from Randomization
Continuing Medical
Implementation CM Gibson 2002
Treatment
• Beta-Blockers
• Anticoagulation
• Anti-Platelet Agents
• Thrombolysis
• Percutaneous Coronary Interventions
(PCI)
•Risk of all-cause mortality, MI or recurrent angina requiring re-
vascularization
•TIMI score >4 considered high risk ACS
Low Risk Intermediate High Risk Very High Risk
Risk
Non ST ACS 30 Day Death/MI Risk
<3% 3-8 % 8-15 % >15%
No higher risk Rest pain < 20 min. Rest pain > 20 min. Prolonged recurrent
features pains
New onset/
•Single short Crescendo angina •ECG ST •ST depression < 2mm
duration (<10 min.) (Low threshold depression < 2mm With CK-MB or Tn
rest pain severity) •Deep T inversion •ST depression > 2mm
•Crescendo •ECG non-specific (e.g. > 5 mm) –Multiple leads
angina/New onset abnormalities or •T inversion > 2 mm –With pain
angina (Mod normal –Especially in > •Transient ST > 1
severity) •Biomarkers normal mm
5 leads
6 Hour Observation or borderline •Isolated biomarker •Hemodynamic
•ECG X 2 normal, Increased baseline clearly +ve instability
unchanged or non- risk – BP/CHF
specific ST ’s •DM Refractory ischaemia
•Negative •Previous CABG/MI with ST shift
biomarkers X 2 •Recent PCI
D Fitchett, SG Goodman M Gupta, A Langer. Can J Card 2002; 18 (11):1179-1190.
Biochemical markers
Multiples of upper reference limit
Testing for ACS - Serum Markers
• Common Causes of
CK-MB Elevation:
– UA, ACS – Muscular Dystrophy
– Extreme Exercise
– Inflammatory Heart Dz
– Malignant Hyperthermia
– Cardiomyopathies – Reyes Syndrome
– Shock – Rhabdomyolysis
– Cardiac – Delerium Tremens
Surgery/Trauma – Ethanol Poisoning, chronic
– Trauma
– Dermatomyositis
– Myopathic Disorders
TROPONIN I LEVELS PREDICT RISK
UA/NSTEMI 9/00 OF MORTALITY IN UA/NSTEMI
7.5
8
Mortality at 42 Days (% of patients)
6.0
6
3.7
4 3.4
1.7
2
1.0
831 174 148 134 50 67
0
0 to <0.4 0.4 to <1.0 1.0 to <2.0 2.0 to <5.0 5.0 to <9.0 >9.0
Cardiac Troponin I (ng/ml)
Risk Ratio 1.0 1.8 3.5 3.9 6.2 7.8
Antman
N Engl J Med. 335:1342, 1996
Testing for ACS - Troponins
• AMI:Cardiac Troponin I (cTnI) and cTnT
• Elevates in 6 hrs
• peaks in 12 h
• Remain elevated for 7 to 10 days
• Higher specificity than CK-MB
• Controversy = Troponins are found to be elevated
in Renal Failure pts without proof of ACS/AMI
Testing for ACS - Serum Markers
• Using Myoglobin, CK-MB, and cTnI
initially and at 3 hours = 90% of AMI pts
diagnosed
ACS ED Observations
• Chest Pain Units have shown to be able to
Discharge 82% of pts after set observation
– Serial Enzymes at 0, 3, 6, 9 hrs
– Serial EKG’s
– Followed by Echo and Stress test to rule out
ACS
General Measures
• Rest, oxygen and EKG monitoring
• Exclude secondary causes (10-15% )
Anemia
Arrythmias
Heart Failure
Hypoxemia
Infection
Uncontrolled HPT
Stress
Thyrotoxicosis
Continuing Medical
Implementation
Unstable Angina/ACS
Therapeutic Goals-1
• Prevent re-thrombosis & prevent
downstream embolization
– Anti-platelet therapy
• ASA (65-75% early events;50% death/MI 2-
24 months)
• Clopidogrel 300-600 mg 75 mg OD
• Glycoprotein IIB/IIIA inhibitors
– Anti-coagulant therapy ( death MI additional
40%)
• UFH or LMWH
Continuing Medical
Implementation
CURE Trial
Clopidogrel in Unstable Angina
to Prevent Recurrent Ischemic Events
Continuing Medical
Implementation
Unstable Angina/ACS
Therapeutic Goals-1
• Control ischaemia
– -blockers
– Nitrates
– CCB’s
• Relieve Obstruction
– Cardiac cath
– PCI
– CABG
Continuing Medical
Implementation
CHEST PAIN
• Remember, many symptoms overlap.
• Goal in ED is to r/o life threatening causes of
chest pain.
• With appropriate history, physical exam, and
ancillary tests, rule out
* Pneumothorax
* Aortic Dissection
* PE
* Unstable Angina
* MI
* Esophageal Perforation
CHEST PAIN: HISTORY
• When did the pain start?
• What were you doing when the pain started? Were you at rest, eating, walking?
• Did the pain start all of a sudden or gradually build up?
• Can you describe the pain to me?
• Does it radiate anywhere? Neck, jaw,back. down either arm
• Have you had any nausea, vomiting, diaphoresis, or shortness of breath?
• Have you had any fevers, chills, URI symptoms, or cough?
• Have you been on any long plane trips, car rides, recent surgeries? Have you been
bed- bound? Have you noticed any swelling in your legs?
• Have you had any tearing sensation in your back/chest?
• Does anything make the pain better or worse? Activity, food, deep breath, position,
movement, NTG.
• Have you ever had this type of pain before. If so what was your diagnosis at that
time?
• When was the last time you had a stress test, echo, cardiac cath, etc.
• Remember to review risk factors!
Thank you
Questions?
