MD Notes

creation date: 2025-07-06 17:01
tags: Workups

Chest Pain

Differential Diagnosis

Life-threatening conditions

The most concerning conditions can be summarized by the mnemonic “PETMAC”: PE, Esophageal rupture, Tension ptx, MI, Aortic dissection, Cardiac tamponade

These conditions require referral to the emergency department:

Other conditions include:
Cardiac

  • Stable myocardial ischemia (angina)
  • Heart failure
  • Pericarditis/myopericarditis
  • Myocarditis - not necessarily emergent but can worsen rapidly so consider sending to ED
  • Stress cardiomyopathy (takotsubo)
  • Aortic valve disease
  • Mitral valve disease
    Pulmonary
  • Pneumothorax
  • Pneumonia
  • Malignancy
  • Asthma/COPD
  • Pleuritis
  • Sarcoidosis
  • Acute chest syndrome (anemia)
  • Pulmonary hypertension
    Gastrointestinal (symptoms after eating)
  • Gastroesophageal reflux disease
  • Peptic ulcer disease
  • Esophageal motility disorders
  • Esophagitis
  • Eosinophilic esophagitis
  • Hiatal hernia
  • Cholecystitis and associated gallbladder diseases
  • Pancreatitis
    Musculoskeletal (worse with palpation/movement)
  • Isolated MSK chest pain syndrome
  • Rheumatic diseases
  • Rib pain
  • Trauma
    Psychiatric
  • Panic attack
  • Depression
  • Somatic symptom disorder
  • Factitious disorder (Munchausen syndrome)
    Drugs
  • Cocaine use complications
  • Methamphetamine intoxication
    Others
  • Herpes zoster (Shingles)
  • Intimate partner violence

Initial Evaluation

Outpatient Triage

Assessment should be made to determine if emergency department attention is required.

Send to emergency department if vitals or oxygen saturation are unstable and/or signs or symptoms of life-threatening conditions:

  • Anginal symptoms at rest, new-onset, or unpredictable/progressive (ACS)
  • Acute chest/back pain that is severe, sharp, and has a ripping or tearing quality (aortic dissection/rupture)
  • Pleuritic chest pain with dyspnea, tachycardia, hypotension, muffled heart sounds, and/or elevated JVP (cardiac tamponade)
  • Pleuritic chest pain, cough, and symptoms of DVT (pulmonary embolism)
  • Sudden onset pleuretic pain with dyspnea and hemodynamic instability (tension pneumothorax)
  • Excruciating retrosternal chest pain with vomiting (Boerhaave syndrome / esophageal perforation)

Emergency Department Measures

Triage should identify life threatening chest pain. In general, life threatening etiology is assumed if patient also has any of the following:

  • Abnormal vitals
  • Obvious distress
  • Signs of hypoperfusion
  • Abrupt onset of thoracic or abdominal pain with sharp, tearing, and/or ripping quality
  • Variation in pulse (eg. absence) and/or blood pressure (eg. difference between arms)

For unstable patients, general measures are:

  • Airway management and ventilatory support
  • Supplemental oxygen typically targeting 90-94%
  • Establish IV access
  • Establish continuous cardiac monitoring and obtain ECG

Depending on findings and features, next steps may be:

  • Addressing dysrhythmias
  • Provide circulatory support if shock (eg. thoracostomy for tension ptx)
  • Administer aspirin (if not aortic pathology or GI tract perforation)
  • Chest x-ray and bedside ultrasound

Assessment and Investigations

Physical examination

  • Life-threatening cause may result in anxiety/distress with abnormal vital signs
  • Otherwise, generally normal findings
  • PE: focal wheeze, asymmetric extremity swelling
  • Ptx: unilateral decreased breath sounds
  • GI etiology: epigastric tenderness and FIT positive
  • MSK: pain worse on palpation

Chest radiograph
Often nonspecific or normal but findings seen may include:

  • Kerley B lines, peribronchial cuffing, cephalization of blood vessels (CHF)
  • Pleural effusion (PE, aortic dissection, pneumonia, mediastinitis, CHF, etc.)
  • Mediastinal/aortic knob widening (aortic dissection)
  • Cardiomegaly (pericardial effusion, cardiomyopathy, etc.)
  • Pneumothorax
  • Pneumoperitoneum (perforated abdominal viscus)

Laboratory studies
Based on clinical suspicion:

  • Troponin for acute MI
  • D-dimer for PE (with sufficient pretest probability)
  • CBC (inflammatory or infectious etiology, possibly anemia)
  • BNP and NT-proBNP for acute heart failure
  • Coagulation indices if theres concern for hemorrhage
  • Liver tests for biliary tract or pancreatitis

Bedside ultrasonography
Findings may include:

  • Pericardial tamponade - pericardial effusion, cardiac chamber collapse, abnormal septal motion with respiratory variation, IVC plethora
  • ACS - cardiac wall motion abnormalities
  • PE - right heart strain, McConnell’s sign (akinesis of mid-free wall of RV)
  • Aortic dissection - pericardial effusion, intimal flap, or aortic outflow tract diameter >35 mm
  • Ptx - lung point, absence of lung sliding
  • Pna - focal b-lines (“comet tails”), irregular pleural morphology, air bronchograms
  • Pleural effusion
  • Heart failure
  • Myocarditis/cardiomyopathy - LV dilation, systolic dysfunction

CT imaging
Identification/diagnosis/rule-out of:

  • Aortic dissection
  • PE
  • Mediastinal pathology

References

Tools / Guidelines

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