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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