Differential Diagnosis of chest pain. by Dr Joshua Walinjom

1. Differential Diagnosis of Chest Pain
By Dr Joshua Walinjom

2. Plan
 Introduction
 Common causes:
 Presentation
 Clinical / Paraclinical Diagnosis
 Treatment
 Conclusion.

3. Introduction
 Chest pain is a common chief complaint
 In the UK, 1% to 2% of adults attend primary
care each year with a new presentation of chest
pain.
 usually divided into cardiac and non-cardiac
causes.

4. Aetiology
Created by BMJ; based on data from Kohn MA, Kwan E, Gupta M, et al.
Prevalence of acute myocardial infarction and other serious diagnoses in
patients presenting to an urban emergency department with chest pain. J Emerg
Med. 2005 Nov;29(4):383-90

5. Urgent considerations
 Use an ABCDE (airway, breathing,
circulation, disability, exposure) approach to
systematically assess and treat the patient.
 Treat life-threatening problems before
moving onto the next part of the
assessment.

6. Approach
 History taking
 Physical examination

7. CP Differential Diagnosis;
1. Acute coronary syndrome
 Acute coronary syndromes include
-Unstable angina
-Non–ST-segment elevation myocardial infarction
(NSTEMI)
-ST-segment elevation myocardial infarction
(STEMI)

8. CP Differential Diagnosis;
Acute coronary syndrome
 HISTORY:
central chest pressure, squeezing, or heaviness;
radiation to jaw or upper extremities;
Associated nausea, vomiting, dyspnoea, dizziness

9. CP Differential Diagnosis;
Acute coronary syndrome
 Examination
may be normal;
jugular venous distention,
S4 gallop,
holosystolic murmur (mitral regurgitation),
bibasilar rales; hypotensive, may be tachycardic,
bradycardic, or hypoxic depending on severity of
ischaemia

10. CP Differential Diagnosis;
Acute coronary syndrome
 INVESTIGATION
ECG, Troponin, Chest Xray ,
Coronary angiography
bloods

11. CP Differential Diagnosis;
Acute coronary syndrome

12. CP Differential Diagnosis;
Acute coronary syndrome

13. CP Differential Diagnosis;
Acute coronary syndrome
Treatment
 Oxygen , Aspirin, Nitrates, Morphine
 Fondaparinux 2.5 mg sc
 Clopidogrel 300–600 mg, then 75 mg then OD
or Prasugrel 60 mg orally once, followed by 10 mg OD
or Ticagrelor 180mg then 90mg BD
 Bisoprolol 2.5–5 mg OD
 Angiogram +/- Anglioplasty

14. CP Differential Diagnosis;
2.Pneumonia
 History :productive or dry cough, fever, pleuritic pain
associated with shortness of breath; may have rigors,
myalgias, and arthralgias
 Exam : decreased breath sounds, rales, wheezing,
bronchial breath sounds, dullness to percussion, and
increased tactile fremitus observed with severe
consolidation

15. Differential
Pneumonia
Investigation
 C Xray
 FBC
 sputum culture
 blood culture
Treatment
 Per Hospital protocol

16. CP Differential Diagnosis;
3. GORD
History
 chest pain, typically retrosternal burning with eating
large or fatty meals that can be reproduced with lying
supine and relieved by sitting up; relieved by
antacids; reflux symptoms

17. CP Differential Diagnosis;
GORD

18. CP Differential Diagnosis:
GORD
 Exam
Oesophago-Gastro-Duodenoscopy if persisent
Treatement
 PPI
 Antacid

19. CP Differential Diagnosis:
4.Costochondritis
 History: focal chest wall pain, may have known
precipitating injury; aggravated by sneezing,
coughing, deep inspiration, or twisting of the chest.
 Exam: reproducible pain on
chest wall palpation,
especially at the
costochondral junctions
 C Xray Normal
 Treatment NSAIDS.

20. CP Differential Diagnosis:
5. Anxiety or panic disorder
 History: sharp chest pain with anxiety, dizziness or
faintness, palpitations, sweating, trembling or
shaking, fear of dying or going insane,
paraesthesiae, chills or hot flushes, breathlessness
or choking sensation
 O/E: hyperventilation, examination otherwise normal
 Investigations: C Xray Normal . ECG Normal or Sinus
Tachy

21. CP Differential Diagnosis:
5. Anxiety or panic disorder
 HADS (hospital anxiety and depression scale) score:
may have a score >11
 Panic attack :
reassurance ±
benzodiazepines
and SSRIs or SNRIs.
? Psychiatry input

22. CP Differential Diagnosis:
6. Pulmonary embolism
History:
 chest pain that is sharp and pleuritic in nature;
 shortness of breath; haemoptysis
 syncope;
 immobilisation, orthopaedic procedures,
 oral contraceptive use, previous PE,
hypercoagulable states, or recent travel over long
distances;
 unilateral swollen lower leg

23. CP Differential Diagnosis:
6. Pulmonary embolism
O/E:
 may have tachycardia,
 loud P2, right-sided S4 gallop,
 jugular venous distention,
 fever, right ventricular lift;
 massive PE may cause
 hypotension
 PE likely’ (Wells score >4)

24. CP Differential Diagnosis:
6. Pulmonary embolism
Investigations :
 ECG: sinus tachycardia; usually nonspecific but may
show S1, Q3, and T3 pattern

25. CP Differential Diagnosis:
6. Pulmonary embolism
Investigations :
 D-dimer
 chest x-ray:
normal +:
Westermark sign;
pleural effusion

26. CP Differential Diagnosis:
6. Pulmonary embolism
Investigations :
 CT pulmonary
angiography
 troponin

27. CP Differential Diagnosis:
6. Pulmonary embolism
Investigations :
 echocardiography: may show acute right ventricular
dilation or hypokinesis
 Duplex ultrasonography
 ventilation-perfusion (V/Q) scan

28. CP Differential Diagnosis:
6. Pulmonary embolism
Treatment :
 DOAC
- apixaban: 10 mg orally twice daily for 7 days, followed
by 5 mg twice daily
- rivaroxaban: 15 mg orally twice daily for 21 days,
followed by 20 mg once daily
 Heparin LMWH / UFH

29. CP Differential Diagnosis:
6. Pulmonary embolism
Treatment :
 Thrombolysis Indications. unexplainable shock
and/or persistent hypotension. alteplase:
 Surgical embolectomy
(persistent SBP ≤ 90 mm Hg
after fluid therapy and
oxygen or if vasopressor
therapy is required)

30. CP Differential Diagnosis:
7. Pericarditis
History
 viral prodrome; sharp pleuritic chest discomfort
provoked by lying supine and improved with sitting
up;
 associated dry cough, fever, myalgias, or arthralgias;
history of possible causes such as radiation
exposure, collagen vascular disease,
 recent myocardial infarction, or uraemia

31. CP Differential Diagnosis:
7. Pericarditis
O/E
 tachycardia and friction rub;
 jugular venous distention and
 pulsus paradoxus indicate
effusion causing tamponade

32. CP Differential Diagnosis:
7. Pericarditis
Investigations ECG

33. CP Differential Diagnosis:
7. Pericarditis
Investigations CX ray
 usually normal; enlarged cardiac silhouette (globular
heart) if pericardial effusion present

34. CP Differential Diagnosis:
7. Pericarditis
Investigations
 echocardiography: normal or shows small effusion

35. CP Differential Diagnosis:
7. Pericarditis
Treatment
 idiopathic or viral =
NSAID + Colchicine
 not idiopathic or viral
(non-purulent) =
treatment of the
underlying cause
pericardial calcifications

36. CP Differential Diagnosis:
8. Aortic dissection
History
 acute substernal tearing sensation, with radiation to
interscapular region of the back;
 stroke,
 acute MI
 dyspnoea - AR;
 Hypotension –
cardiac tamponade;
 history of hypertension,
 Marfan's syndrome,
 Ehlers-Danlos syndrome, or syphilis

37. CP Differential Diagnosis:
8. Aortic dissection
O/E
 unequal pulses or blood pressures in both arms;
 new diastolic murmur due to aortic regurgitation;
 muffled heart sounds -cardiac tamponade;
 new focal neurological -carotid or vertebral arteries

38. CP Differential Diagnosis:
8. Aortic dissection
Investigations
 chest x-ray: widened mediastinum

39. CP Differential Diagnosis:
8. Aortic dissection
Investigations
 CT chest with contrast

40. CP Differential Diagnosis:
8. Aortic dissection
Treatment
Goal
 ABCDE
 Heart rate <60 beats per minute
 Systolic blood pressure 100-120 mmHg.
 1st line Labetalol
 Diltiazem , verapamil

41. CP Differential Diagnosis:
8. Valvular heart disease
Aortic stenosis
History
 age over 60 yrs;
 triad of 'SAD'
 Syncope
(exertional)
 Angina
 Dyspnoea

42. CP Differential Diagnosis:
8. Valvular heart disease
Aortic stenosis
O/E
 ejection systolic murmur that radiates to the neck;
 obliteration of S2 = severe stenosis;
 delayed upstroke on palpation of carotid pulse

43. CP Differential Diagnosis:
8. Valvular heart disease
Aortic stenosis
Investigation:
 ECG: LVH + strain

44. CP Differential Diagnosis:
8. Valvular heart disease
Aortic stenosis
Investigation:
 chest x-ray:
calcified aortic valve

45. CP Differential Diagnosis:
8. Valvular heart disease
Aortic stenosis
Investigation:
 echocardiogram: reduced valve surface area;
elevated velocities through the aortic valve
 The ACC/AHA

46. CP Differential Diagnosis:
8. Valvular heart disease
Aortic stenosis
Treatment
 Medical : statin
 surgical aortic
valve replacement
 TAVI

47. CP Differential Diagnosis:
9. Pneumothorax
History
 acute, pleuritic chest pain, shortness of breath;
 primary spontaneous between ages 20 and 40
years;
 secondary :
COPD; traumatic due
to acute trauma or
iatrogenic;
(tension pneumothorax)

48. CP Differential Diagnosis:
9. Pneumothorax
History
 absent breath sounds,
increased resonance
to percussion; jugular
venous distention,
 tracheal deviation,
 hypotension if
tension pneumothorax
(due to compromise
of the great vessels)

49. CP Differential Diagnosis:
9. Pneumothorax
Treatment
spontaneous pneumothorax
 breathless and/or large pneumothorax ( rim >2 cm)
 1st line – percutaneous aspiration - Aspirate <2.5 L
 If aspiration is unsuccessful (visible rim >2 cm on ches
ray) insert chest drain and admit.
 secondary spontaneous pneumothorax
 breathless or large pneumothorax ( rim >2 cm between
the lung margin and the chest wall)
 1st line chest drain + hospital admission

50. CP Differential Diagnosis:
10. Peptic ulcer disease
 Gastric ulcers: epigastric pain or burning with
onset 5 to 15 minutes after eating and may last for
several hours
 Duodenal ulcers: epigastric pain is relieved by eating
and may return 1 to 4 hours postprandially;
 pain from any ulcer is relieved by antacid;
 risk factors: cigarette smoking, non-steroidal anti-
inflammatory drugs, and chronic alcohol consumption

51. CP Differential Diagnosis:
10. Peptic ulcer disease
O/E
 epigastric tenderness
 Investigation
OGD
H pylori urea breath test or
stool antigen test
Treatment :
PPI + amoxicillin + either clarithromycin or metronidazole

52. CP Differential Diagnosis:
11. Oesophageal spasm
History
 crushing substernal chest pain,
associated dysphagia,
pain does not always
correlate with swallowing,
dysphagia precipitated
by very hot or cold foods,
glyceryl trinitrate can relieve the pain

53. CP Differential Diagnosis:
11. Oesophageal spasm
Investigation
 barium swallow:
corkscrew or
rosary bead
appearance on
barium swallow
 Medication
calcium channel blockers
 Surgery - botulinum toxin

54. CP Differential Diagnosis:
12. Acute cholecystitis
Investigation
 right upper quadrant pain, radiation to the interscapula
area or right shoulder,

55. CP Differential Diagnosis:
12. Acute cholecystitis
Investigation
 LFT, FBC, Abdominal ultrasound
Management
-analgesia
-fluid resuscitation
-antibiotic therapy
-cholecystostomy

56. CP Differential Diagnosis:
13. Acute pancreatitis
History
 epigastric or periumbilical
abdominal pain
that radiates to the back
 history of alcohol
consumption or
 gallstones

57. CP Differential Diagnosis:
13. Acute pancreatitis
O/E
 tachycardic, hypotensive,
febrile, acute distress;
ecchymosis in the
periumbilical region
(Cullen's sign)
and the flank
(Grey-Turner sign)

58. CP Differential Diagnosis:
13. Acute pancreatitis
Investigation
 FBC, Lipase,
Amylase,
 Abdominal
ultrasound
 abdominal
CT scan

59. CP Differential Diagnosis:
13. Acute pancreatitis
Treatment
 fluid resuscitation
 analgesia
 intravenous antibiotics
 Cholecystectomy
- Gall stone

60. CP Differential Diagnosis:
14. Herpes zoster
 unilateral, burning pain in typical dermatome
distribution that may occur before
appearance of rash and
may persist for >1 month
 swab for viral culture and
(PCR):
 Treatment
Famciclovir or aciclovir

61. CP Differential Diagnosis:
Conclusion
 Chest pain is a very common presenting complaint.
 Proper Clerking and thoughtful investigation is vital
 Timely action is imperative and can save the patient.

62. CP Differential Diagnosis:
References
 Braunwald's Heart Disease: A Textbook of
Cardiovascular Medicine, 2-Volume Set, 11th Edition.
 BMJ Best Practice / The BMJ
 Journal of the American College of Cardiology
 ESC Clinical Practice Guidelines

63. MERCI!
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