In this article, we will discuss Differential Diagnosis of Acute Chest Pain. So, let’s get started.
Differential Diagnosis of Acute Chest Pain
A detailed history (regarding quality, location, pattern, provoking and alleviating factors) and physical examination (i.e. vital signs examination of CVS, lungs, abdomen and musculoskeletal system) would help in distinguishing cardiac pain from that of non-cardiac chest pain. Recording the ECG is essential in each and every case of acute chest pain or discomfort. It is important to differentiate between central and peripheral chest pain as it will help in assessing the cause of origin of pain.
Once it has become established that it is cardiac chest pain then its cause has to be established as follows:
1. Anginal pain (stable vs unstable): Stable angina is defined as chest pain brought on exertion and relieved by rest and/or sublingual nitrate. The provoking factors include anaemia, thyrotoxicosis, exposure to cold, heavy meals, stress and sexual activity.
Unstable angina is crescendo angina or rapidly worsening angina with changing pattern of pain during the past 6 weeks (occurs on minimal exertion or at rest and pain is prolonged) without an evidence of
myocardial infarction on ECG or cardiac enzyme elevation (CPK-MB).
2. Prinzmetal’s angina or variant angina, occurs at rest without any provoking factor and is due to coronary vasospasm. The characteristic features of this type of
angina is marked ST segment elevation >4 mm with increase in the height the R-wave in same leads during attack of pain and return of ST-segment to normal with relief of pain.
3. Acute coronary syndrome: Prolonged chest pain lasting for 10-20 minutes may be present due to acute coronary syndrome and these patients even have no abnormalities on ECG and cardiac enzymes may be normal in some cases. Others may have ST-T changes with elevation of cardiac markers like Troponin-T or Troponin I.
Exceptions: Atypical anginal symptoms such as fatigue, exhaustion, fainting sensation or dyspnoea may occur. These are called anginal equivalents. Older patients and patients with distress
may not have chest pain but may have
anginal equivalents as described above.
4. Myocardial infarction: It is characterised by central retrosternal pain which is prolonged and severe and is associated with nausea, vomiting, sweating and dyspnoea. Initial ECG and levels of cardiac enzymes may be normal but subsequent ECGs show serial changes of infarction(i.e. ST-segment elevation, q-wave and T-wave inversion in more than 2 leads) and elevation of cardiac markers, i.e. troponin T and I and raised cardiac enzymes (CPK-MB).
5. Pain due to dissecting aneurysm of aorta: A centrally located excruciating tearing pain lasting for hours and radiating to the back into thoracic region is a characteristic feature. Examination may show acute aortic regurgitation (early diastolic murmur in the aortic area) and evidence of hypertension (the condition is common in hypertensive). X-ray chest may show mediastinal enlargement ECG may be normal.
6. Pain of pericarditis: Acute pericardial pain is not related to effort, is constant and continuous, not aggravated by deep breathing. The pain is ‘sharp’ located in the precordial region and may radiate to
the left or right shoulder. To relieve pain, patient may sit leaning forward (Muslims’ prayer sign). The pericardial rub is often present but its absence does not rule out pericarditis,
7. Pain of pulmonary embolism: Only
large embolism produce pain similar to myocardial infarction. The triad; pain, hemoptysis and pleuritic pain in a patient with deep vein thrombosis suggests acute pulmonary embolisms. The pain is mostly peripheral but may be central, gets aggravated by respiration and coughing.
8. Pneumothorax: Primary pneumothorax is rare. Secondary pneumothorax due to COPD, asthma, cystic fibrosis produce symptoms of underlying disease. The diagnosis is suspected by localised hyper-reasonant note and confirmation is done on X-ray chest
9. Pleural chest due to pleurisy, pneumonia, malignancy is typical knife-like pain worsened by inspiration and coughing. Pleural rub is diagnostic.