Differential diagnosis for chest pain
Common and important causes of chest pain for doctors and medical students
Chest pain - acute or worsening
Diagnosis
Angina (new or unstable)
ST-elevation myocardial infarction
(STEMI)
Non-ST elevation myocardial infarction
(NSTEMI)
Esophagitis and oesophageal spasm
Pulmonary embolus (arising from leg
DVT, silent pelvic vein thrombosis, right
atrial thrombus)
Pneumothorax
Dissecting thoracic aortic aneurysm
Chest wall pain (e.g.costochondritis and
Tietze’s syndrome, strained muscle or rib
injury)
 Beta-blockers. These reduce how hard your heart pumps and slow down your heart rate.
That effect helps the heart muscle handle reduced blood supply, prevent irregular heart
rhythms and reduce damage to your heart.
Evidence
Suggested by: central pain ± radiating to jaw and either arm (left usually). Intermittent, brought
on by exertion, relieved by rest or nitrates, and lasting <30 minutes. May be associated with
transient ST depression or T inversions or, rarely, ST elevation.
Confirmed by: no troponin rise after 12 hours (excludes MI). Stress test showing inducible
ischemia
Suggested by: central chest pain ± radiating to jaw and either arm (left usually). Continuous,
usually over 30 minutes, not relieved by rest or nitrates
Confirmed by: ST elevation 1 mm in limb leads or 2 mm in chest leads on serial ECGs (this is
regarded as sufficient evidence to treat with thrombolysis). Raised troponin indicates episode of
muscle necrosis up to 2 weeks before. Raised troponin may not be present in the first 4 hours
after the onset of chest pain.
Suggested by: central chest pain ± radiating to jaw and either arm (left usually). Continuous,
usually over 30 minutes, not relieved by rest or nitrates
Confirmed by: elevated troponin after 12 hours. T-wave and ST-segment changes but no ST
elevation on serial ECGs
Suggested by: past episodes of pain when supine, after food. Relieved by antacids
Confirmed by: no increase in troponin after 12 hours and no ST-segment changes on ECG.
Improvement with antacids. Esophagitis on endoscopy
Suggested by: central chest pain, also abrupt shortness of breath, cyanosis, tachycardia, loud
second sound in pulmonary area, associated deep vein thrombosis, (DVT) or risk factors such
as cancer, recent surgery, immobility
Confirmed by: V/Q scan with mismatched ventilation and perfusion, spiral (helical) CT (CT-
pulmonary angiogram) showing clot in pulmonary artery
Suggested by: abrupt pain in center or side of chest with abrupt breathlessness. Resonance to
percussion over site
Confirmed by: expiration CXR showing dark field with loss of lung markings outside sharp line
containing lung tissue
Suggested by: ‘tearing pain often radiating to back and not responsive to analgesia, abnormal or
absent peripheral pulses, early diastolic murmur, low blood pressure, and wide mediastinum on
CXR
Confirmed by: loss of single clear lumen on CT scan or MRI
Suggested by: chest pain and localized tenderness of chest wall or chest pain on twisting of
neck or thoracic cage
Confirmed by: no rise in troponin after 12 hours, and no ST-segment changes or T-wave
changes serially on ECG. Response to rest and analgesics
 Statins. These medications lower the levels of cholesterol in your blood by block its
production in the liver. This is important because cholesterol (especially at higher levels) is
what forms plaque that can obstruct arteries.
 Aspirin and antiplatelet medications. These medications help reduce the formation of
blood clots on the plaque in the arteries and, if stent placement happens during PCI, on the
metal surface of the stent itself.
 Anticoagulants. These medications also interfere with clotting but do so in a slightly
different way from antiplatelet drugs and aspirin.
 Nitroglycerin. This medication is very effective at vasodilation, meaning it causes your
blood vessels to widen. That’s why it’s so effective at helping with chest pain from
blockages of blood vessels.
 Pain medications. When chest pain is severe, morphine or other strong pain medications
may help.