TABLE 1-1 - Differential Diagnosis of Chest Pain

Diagnosis	Characteristic Features	Physical Findings	Diagnostic Tests (Finding)
Angina	Substernal, exertional, relieved with rest or nitroglycerin; lasts 5-15 minutes	S3, S4 or MR murmur during pain; vascular bruits	ECG, Exercise stress test (ST depression)
Myocardial infarction	Similar to angina, only more severe and prolonged	S3, S4 congestive heart failure, tachycardia	ECG (ST depression or elevation); increased cardiac enzymes
Aortic stenosis	Similar to angina	Murmur of aortic stenosis	Echocardiogram (stenotic aortic valve)
Aortic dissection	Sudden, severe, tearing pain, radiating to the back	Unequal arm pulses and BP; hypertension; AI murmur	TEE, MRI, or CT scan (dissection flap)
Pericarditis	Sharp, pleuritic pain that is worse with swallowing and worse when lying down; may radiate to shoulder	Pericardial friction rub	ECG (diffuse ST elevation)
Pulmonary hypertension	Similar to angina	Loud P2, signs of right heart failure	Echocardiogram, Swan-Ganz catheter (increased PA pressure)
Pulmonary embolism	Sudden onset of pleuritic chest pain associated with shortness of breath	Tachypnea, hypoxia, tachycardia, signs of acute right heart failure	VQ scan, spiral CT scan, PA angiogram (perfusion or filling defect)
Pneumonia	Sharp, pleuritic pain associated with cough, shortness of breath	Rhonchi over affected lung area	CXR (pulmonary infiltrate)
Spontaneous pneumothorax	Sudden sharp chest pain	Decreased breath sounds and hyper-resonance over affected lung	CXR (air in pleural space; lung collapse)
Esophageal rupture	Follows vomiting or esophageal instrumentation, constant	Mediastinal crunch	CXR (pneumothorax, left pleural effusion), Barium swallow
Gastroesophageal reflux	Burning substernal pain aggravated by eating or lying down	None	Upper GI series, endoscopy (reflux of gastric contents)
Esophageal spasm	Sudden severe pain that can mimic angina	None	Esophageal manometry (increased esophageal pressure)
Musculoskeletal pain	Sharp or achy pain, worse with movement, tender to touch	Tenderness over involved area	None
Herpes zoster	Sharp, burning pain in dermatomal distribution	Vesicular rash over affected area	Tzanck prep of vesicular fluid (giant cells)
Anxiety	Variable quality and location of pain; stressful situations	Chest wall tenderness	Diagnosis of exclusion

MR: mitral regurgitation; ECG: electrocardiogram; BP: blood pressure; AI: aortic insufficiency; TEE: transesophageal echocardiogram; MRI: magnetic resonance imaging; PA: pulmonary artery;VQ: ventilation/perfusion; CT: computed tomography; CXR: chest x-ray; GI: gastrointestinal.