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Chest Pain Chest Pain Differential Diagnosis


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									                  Chest Pain

                          Marty Short, MD
                          Medicine Clerkship Director
                          Marquette Campus

Chest Pain

 The primary goal - determine the diagnosis and
 assess safety
 Respiratory and hemodynamic status
 Focused history and physical, labs, diagnostic
 Risk of life threatening conditions.

Differential Diagnosis

 Acute coronary syndrome
 Pulmonary embolus
 Peptic ulcer disease
 Aortic dissection

Differential Diagnosis cont.

 Esophageal spasm
 Herpes Zoster
 Musculoskeletal problems

Determined not MI

  GERD         30%        Chest wall syndrome
  GE motility 13%         28%
  PUD          10%        Pericarditis 4%
  Gallstones 5%           Pneumonia 2%
  Ischemic heart          PE            2%
 disease      31%

Case One

 68 yo male with history of hypertension
 presents with sudden onset of severe
 retrosternal chest pain of one hour duration.
 The pain radiates to the back and is rated as
 10/10. BP 170/90.

Case Two

 A 58 year old female presents to the ED in
 obvious distress. She is diaphoretic with a BP
 of 180/100 and a HR of 100. She has had
 three episodes of severe substernal chest pain
 with sudden onset, radiating to the arms,
 lasting for 10-15 minute each.

Case Three

 A 50 yo physician is brought to the ED by family car
 with a cc of ‘indigestion.’ He was playing hockey and
 developed heartburn and nausea. He admits to
 retrosternal pressure. VS are stable. He ate one
 pound of barbeque spare ribs two hours ago along
 with a beer. He takes medication daily for heartburn.

Initial Evaluation

 If you suspect an MI or unstable angina, NTG
 and ASA and tell your team!
 Time is myocardium
 Provide for the patients general comfort ie
 pain medication

Characterize the Pain

 May deny ‘pain’ ask about pressure, burning,
 Rate pain on 1-10 format
 What do they think it is?

Associated Features

 Nausea and vomiting
 Fever and or rigors

Medical History

 Any similar episodes
 History of DM, HTN, hyperlipidemia, PUD,
 PVAD, GI bleed?
 Health habits, medications
 Family History

Physical exam

 Patient’s overall appearance
 Vital signs
 Exam focusing on cardiovascular, pulmonary,
 GI , and musculoskeletal

 Comparison of Pain Patterns across
     the differential diagnosis


 Squeezing, heavy, burning
 Retrosternal +/- radiation to the jaw, neck, arm, back
 or shoulder
 Precipitated with activity, relieved with rest or NTG.
 Duration 2-10 min.
 Unstable Angina 10-20 min.
 May have S4 or MR

Acute Mi

 Similar pain pattern to angina
 Differs in severity and duration
 Pain unrelieved with NTG
 Atypical pain in women
 ‘Silent MI’ with diabetes
 Physical exam may reveal CHF, S3, S4 or
 arrythymias, MR


 Sharp pleuritic chest pain
 Retrosternal, may radiate to the shoulder
 May have friction rub
 Paradoxical pulse, cardiac tamponade may be

Thoracic Aortic Dissection

 Abrupt onset, unrelenting pain, tearing or
 Pain can migrate
 May radiate to the back
 Exam- HTN, hypotension, Pulmonary edema,
 Pulses may be absent


 Pain variable in severity, location and duration
 Pleuritic component
 Exam can show tachypnea, rales, fever,
 decreased air exchange.

Pulmonary Embolus

 Abrupt onset of pleuritic pain lasting minutes
 to hours
 Located to the site of the embolus
 Impending feeling of doom
 Tachypnea, tachycardia, hypotension are


 Sudden onset of pleuritic pain
 Pain on the side of the pneumothorax, several
 hours duration
 Exam may show decreased air exchange,
 tympany on the involved side, tracheal

Esophageal Reflux

 Pain is a retrosternal burning, can radiate to
 the shoulder
 Aggravated by high fat meals
 Duration 10-60 minutes
 May get relief with antacids

Esophageal Spasm

 Pain can be very severe
 It is substernal
 Often associated with dysphagia
 May be relieved with NTG
 Usually occurs at rest but may be brought on
 by swallowing or emotional stress

Peptic Ulcer

 Pain is a burning or gnawing
 Located epigastic region or substernal, can
 radiate to the back
 Relieved with eating, antacids


 Pain described as burning, pressure
 Location RUQ, may radiate to the right scapula or
 Duration - hours
 Nausea and vomiting are common
 Fever, elevated WBCs
 RUQ pain with palpation is almost always there


 Pain variable as is duration and intensity.
 Can be aggravated by movement
 May be reproducible on exam
 The presence of chest wall pain does not
 exclude another diagnosis

Herpes Zoster

 Pain is in a dermatomal distribution
 May not have a rash early on
 You have to look for the rash
 Clinical case

What Next?

 Formulate a differential diagnosis
 Determine the appropriate diagnostic tests
 Often many studies will be ordered
 The basics…EKG, chest x-ray, CBC, Cardiac

Acute Coronary Syndrome

 EKG this is critical
 Cardiac markers, CK, troponin-I, myoglobin
 Vital signs
 Physical exam
 Angina or MI?

Acute Coronary Syndrome

 Thrombolytics vs urgent catheterization
 ASA and NTG
 ICU or Stepdown bed
 Observation and stresstesting if less clear
 Follow serial cardiac enzymes

Cardiac Markers

 Troponin I rises 3-6 hours after acute MI and
 remains elevated for 14 days.
 CK-MB begins to rise in 4 hours, peaks 18-24,
 decreases 3-4 days. Single ED assay 34%
 Myoglobin sensitive early marker but not


 Chest x-ray
 ABG’s O2 saturation
 CBC, Blood cultures, sputum cx
 Treatment based on assumed type of
 pneumonia and comorbidity


  Exam is crucial
  Chest x-ray
  Chest tube is the primary treatment. Small
  pneumothorax may be observed

Pulmonary Embolus

 High index of suspicion is crucial
 Many protocols exist using clinical prediction rules, venous
 dopplers, VQ scans, spiral CT scans, angiography and D-dimer
 Treatment is anticoagulation but do hypercoaguable workup first
 Thrombolytic agents if hypotensive
 EKG, sinus tachycardia, new onset a. fib. Or flutter, S1, Q3,
 Inverted T3

Thoracic Aortic Dissection

 CT, MRI, TEE, Aortogram
 ICU admit for hemodynamic monitoring
 Betablockers with a goal of 60bpm
 Sodium nitroprusside to decrease arterial pressure
 Surgical treatment
 Chest x-ray may show mediastinal widening

Thoracic Aortic Dissection

 Stanford classification, ascending aorta-class A, descending
 aorta-class B.
 Stanford class A best managed surgically, B medically
 Class A can closely mimic AMI
 Coronary Ostia can be involved and the EKG may show ST
 Elevation in 8%. ST changes may be seen in 42%
 No single test clearly delineates between AMI and TAD.


 EKG may show diffuse ST segment elevation
 and PR segment deviation
 CPK levels may rise but small increases
 Changes not localized as with MI


 If GERD is suspected short acting antacids
 are tried often with viscous lidocaine.
 Rapid relief suggests acid reflux or ulcer
 Rarely PH probes are used
 Diagnosis often made after cardiac workup

Peptic Ulcer Disease

 May be relieved with antacids
 Anemia and heme positive stools if bleeding
 Often associated with NSAID use or H. Pylori
 Endoscopy is the most sensitive means of diagnosis
 Barium studies are still used but can not detect small
 ulcers or be used for treatment or biopsy

Esophageal Spasm

 Barium swallow shows uncoordinated contractions
 Manometric studies are also used.
 Spasm can be episodic so studies may be normal
 Exclude cardiac disease first
 Treatment is with nitrates, calcium channel blockers

Case One

 Sudden onset severe retrosternal chest pressure
 radiating to the back and neck, pain 1 hour duration.
 68 yo male, HTN, Smoker. meds HCTZ
 No nausea, no dyspnea
 Exam reveals a diastolic murmur loudest at the
 aortic area
 EKG, CBC, cardiac markers are all normal

Differential Diagnosis

 MI with coexisting AI
 Esophageal spasm

Chest X-Ray Shows Widened

Further Workup

 MRI/MRA revealed dissecting aortic aneurysm
 In this case there was a significant degree of aortic
 regurgitation and the patient had valve replacement
 along with repair of the aneurysm
 Treatment can be medical or surgical depending on
 size and location

Case Two

 58 year old female with 3 episodes of severe
 substernal chest pain radiating to the arms, lasting
 10-15 min. Diaphoretic with a BP of 180/100 and HR
 of 100.
 Known HTN, postmenopausal, family history of CAD
 Onset of symptoms while eating
 Pain in ED relieved with NTG
 No fever is present, no nausea

Differential Diagnosis

 Acute coronary syndrome
 Gastroesophageal spasm

Case Two

 EKG is normal
 Cardiac markers are normal
 Chest x-ray and CBC are normal, amylase, lipase and liver tests
 are normal
 The patient is admitted and MI is ruled out
 Stress testing is performed with echocardiogram and is normal
 Barium Swallow reveals esophageal spasm

Case Three

 50 year old male with onset of “indigestion” while
 playing hockey. Known GERD treated with proton
 pump inhibitors.
 Pain described as retrosternal pressure,7/10,
 associated with nausea, duration one hour
 No radiation, no dyspnea
 No other relevant family or medical history

Differential Diagnosis

 Acute MI

Case Three

 The patient is diaphoretic
 VS BP 90/60, afebrile
 Enzymes are all normal
 Chest x-ray is normal
 Labs are all normal

Case Three

 The EKG shows ST elevation in leads 2, 3 and
 Urgent catheterization and PTCA was
 Thrombolytics would be an alternative if PTCA
 not available
 This patient had near occlusion of the RCA

Case Three

 Remember to look for RV infarct with inferior MI,
 posterior MI may be ‘silent’ on standard 12 lead EKG
 Can use Right sided leads to look for ST elevation
 Associated with RV failure and hypotension
 Echocardiogram is helpful to assess degree of
 Treatment is volume expansion

Failure to Diagnose Chest Pain

 Failure to diagnose MI most common cause of
 malpractice in Massachusetts from 1995-2000. (one
 specific company)
 27% of all indemnity paid for malpractice cases
 60% of dissecting thoracic aneurysm were not
 suspected by the ED physicians

Malpractice Companies’

 EKG done and accurately interpreted. (Not done
 25%) Must compare to previous tracing
 Thorough history and physical
 Remember a normal EKG does not exclude
 coronary ischemia
 1 out of 5 plaintiffs had no cardiac risk factors or
 previous history


 Most chest pain is not an MI
 Differential diagnosis essential
 Consider life threatening first
 History and exam provide clues
 Diagnostic tests based on differential
 Remember think PE and TAD


 AHA/ACC Acute Coronary Syndrome Clinical
 Data Standards
 Harrison’s “Principles of Internal Medicine”
 eMedicine-Myocardial Infarction


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