Differential Diagnosis of Acute Chest Pain
Differential Diagnosis of Acute Chest Pain
Cause grouping
Cardiac
Differentials ACS
Aortic dissection Pericarditis
Myocarditis
Other cardiac differentials
Classical history
Classic examination findings
Investigation findings (Initial test, diagnostic test)
?Crushing central chest pain
?May be normal
?ECG: ST elevation (or new
?Radiates to neck/left arm
?General: sweaty, SOB, in pain
LBBB), inverted T waves, Q
?Associated
?CVS: S4 gallop, JVP distension,
waves
nausea/SOB/sweatiness
signs of heart failure,
?Troponin: increased (but
?Cardiovascular risk factors
brady/tachycardic
normal in unstable angina)
?CXR: normal or signs of heart
failure
?Coronary angiography
?Tearing chest pain of very sudden ?Unequal arm pulses or BPs
?CXR: widened mediastinum
onset
?May be acute aortic regurgitation ?CT angio or transoesophageal
?Radiates to back
?May be new neurological
echo
?Pain in other sites e.g. arms, legs, symptoms due to involvement of
?ECG: may be signs of MI
neck, head
carotid/vertebral arteries
?Retrosternal/precordial pleuritic
?Pericardial rub (stepping in snow) Clinical diagnosis
chest pain
?Tachycardia
?ECG: PR depression, saddle-
?Relieved by sitting forward
?JVP distension and pulsus
shaped ST elevation
?May radiate to trapezius
paradoxus may indicate tamponade ?CXR: may be globular heart if
ridge/neck/shoulder
pericardial effusion present
?Viral prodrome common
?Echo: if pericardial effusion
suspected
?Chest pain
?Signs of congestive cardiac failure ?ECG: diffuse T wave inversions,
?Palpitations
?Soft S1, S4 gallop
ST elevation/depression
?Fever
?Fever
?Inflammatory markers: raised
?Fatigue
?Tachypnoea
?Troponin: raised
?Dyspnoea
?Serology: identify cause
?Myocardial biopsy (if required)
Stable angina; tamponade; mitral valve prolapse; pulmonary hypertension; aortic stenosis; arrhythmias
Definitive management (remember ABCDE first) ?MONAC ?Primary coronary intervention
?Type A surgical repair ?Type B BP control
?NSAIDs ?Treat cause (if known)
?Supportive ?Bed rest
Respiratory Pulmonary embolism
?Pleuritic chest pain ?Dyspnoea ?Haemoptysis ?Risk factors (long haul flight, recent surgery, immobility)
Pneumonia
?Fever ?Shortness of breath ?Productive cough ?Pleuritic chest pain ?Confusion
Pneumothorax
?Sudden onset pleuritic chest pain ?May be SOB if large ?Risk factors e.g. Marfan's appearance, COPD/asthma
Pleurisy
Other respiratory differentials
?Pleuritic chest pain ?May be: dry cough, fever, dyspnoea
Lung cancer
?CVS: tachycardia, JVP distension, RV heave, loud P2, right S4 ?RS: tachypnoea, clear chest ?CALVES: look for DVT ?SBP ................
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