This presentation includes important differential diagnosis of chest pain

1. ‫الرحیم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

2. DIFFERENTIAL DIAGNOSIS
OF CHEST PAIN

3. COMMON CAUSES OF CHEST PAIN
Cardiac Aortic Esophageal
• Angina pectoris Dissecting aneurysm Reflux oesophagitis
• Myocardial infarction Lung and pleura
(respiratory)
Diffuse esophageal spasm
• Myocardial infarction • Pleurisy Musculoskeletal
Mitral valve prolapse • Pneumothorax Hyper adrenergic state
Pericarditis • Pulmonary embolism Cocaine intoxication
Hypertrophic
Cardiomyopathy
Intra-abdominal conditions Anxiety
• Aortic
stenosis/regurgitation

4. RESPIRATORY CHEST PAIN
Respiratory chest pain most commonly arises from
parietal pleura (including the diaphragmatic pleura),
chest wall and the mediastinal structures. Lung
parenchyma and visceral pleura are insensitive to most
painful stimuli. The peripheral part of the diaphragm
and costal portion of parietal pleura are innervated by
somatic intercostal nerves, thus pain felt in these
areas is often localized to cutaneous distribution of
involved neurons over the adjacent chest wall. Central
portion of diaphragm is innervated by phrenic nerve;
therefore central diaphragm irritation is referred to
ipsilateral shoulder tip or even the neck.

5. ANGINA PECTORIS
Pain is usually retrosternal in location and
brought on by exertion. It is relieved by
rest and sublingual nitrates. Pain seldom
lasts more than 20 minutes. Character of
the pain is squeezing, crushing or aching.
Pain commonly radiates to left arm and
less commonly to right arm, throat, back,
chin and epigastrium. Often the pain
comes on while walking uphill after a

6. PHYSICAL SIGNS OF MYOCARDIAL
ISCHEMIA
The presence of one or more of signs during an attack of pain may be
suggestive.
Rise in blood pressure and heart rate
Fourth heart sound
Murmur of mitral regurgitation due to papillary muscle dysfunction
 Dyskinetic segment around the apex
 Paradoxical splitting of second heart sound
 Relief of pain by carotid sinus massage (Levine test)

7. INVESTIGATIONS
Salient investigations include
1. Electrocardiography
2. Echocardiography
3. Exercise testing
4. Coronary angiography.

8. MYOCARDIAL INFARCTION
A history of previous episodes of angina pain with recent worsening
may be present. The pain of infarction is similar in character and
distribution is similar to angina pain. But it is more severe, prolonged
(lasts more than 20 minutes), persisting at rest and not responding to
nitrates. There may be vomiting, anxiety and a feeling of impending
death.
One or more of the physical signs of myocardial ischemia may be
present (refer above).
Other common physical signs include pallor, sweating, cyanosis,
hypotension, arrhythmias (most commonly ventricular ectopic beats),
pericardial friction rub, signs of congestive heart failure and
cardiogenic shock.
 Salient investigations include serial electrocardiograms and cardiac

9. MITRAL VALVE PROLAPSE
• History of non-specific chest pain is atypical.
• Physical findings include a mid-systolic click and a
late systolic murmur varying with posture and
respiration.
• Echocardiography can confirm the diagnosis.

10. PERICARDITIS
• Pericardial pain is felt retrosternally to the left of the
sternum or in the left or right shoulder. Pain is
aggravated by deep breathing and rotating the trunk.
It is worse in the lying down position and is relieved by
sitting up and leanig forwards.
• Physical findings include the characteristic
pericardia! friction rub and evidence of pericardial
effusion.
• Salient investigations include electrocardiography
and echocardiography.

11. DISSECTING ANEURYSM OF AORTA
• Sudden onset of severe, sharp, stabbing or tearing pain over the
anterior chest radiating to the back is the usual history.
Dissection is more common in hypertensive males.
• Physical findings include asymmetry of brachial, carotid or femoral
pulses, inappropriate bradycardia and an early diastolic murmur or
aortic regurgitation. Neurological features (hemiparesis, paraparesis,
etc.) may develop due to carotid artery or spinal artery involvement.
• Salient investigations include chest radiography, echocardiography,
CT scanning and aortography.

12. PLEURISY
• Can occur due to inflammation, infection, neoplastic
infiltration or trauma.
• Pleuritic pain is a well-localized pain that is cutting,
stabbing or tearing in character. It is often aggravated
by coughing, sneezing and deep inspiration.
Commonest sites of pleuritic pain are axillae and
beneath the breasts.
• Characteristic sign is a pleural friction rub.

13. PNEUMOTHORAX
• History of sudden onset dyspnea and chest pain following
strenuous exertion or coughing. More common in tall, thin, young
males.
• Clinical features may include cyanosis, tachycardia, hypotension
and distended neck veins. Respiratory system examination reveals
shift of the mediastinum (trachea and apex beat) to the opposite side,
reduced chest movements, hyper-resonant percussion note,
diminished vocal fremitus and vocal resonance, and markedly
reduced to absent breath sounds.
• Diagnosis is confirmed by chest radiography.

14. ACUTE PULMONARY EMBOLISM
• Characteristic clinical setting may be obvious, e.g. prolonged
immobilization, recent surgery, previous history of thromboembolism
or intake of oral contraceptives.
• Clinical examination may reveal calf muscles tenderness, tachypnea
and tachycardia. Respiratory system examination may show a variety
of physical signs like crepitations over the involved area, pleural rub
or pleural effusion.
Cardiovascular system examination may show evidences of acute
right ventricular failure including a right-sided third heart sound,
murmur of pulmonary regurgitation or increased intensity of the
pulmonary component of second heart sound. However, examination
may be entirely normal.
• Salient investigations include chest radiography, electrocardiogram,

15. REFLUX OESOPHAGITIS
• Characteristic history is "heart burn", felt as a burning pain behind
the sternum, radiating to the throat. It typically occurs after heavy
meals and is brought on by bending, lifting or straining. Pain may
occur on lying down in bed at night but relieved by sitting up. Other
symptoms of gastro-oesophageal reflux are odynophagia and
regurgitation of gastric contents into the mouth.
• Salient investigations include oesophagoscopy, barium studies and
acid infusion studies. Often, a sliding hiatus hernia predisposes to
reflux.

16. DIFFUSE ESOPHAGEAL SPASM
• Pain can mimic that of angina and is sometimes precipitated by
exercise and relieved by nitrates. Usually the pain is related to food or
drink intake. Dysphagia is often present.
• Salient investigations include esophageal motility studies, barium
studies and manometry.

17. MUSCULOSKELETAL PAIN
• Common causes of musculoskeletal pains are:
• Intercostal myalgia
• Costochondritis (Tietze's syndrome)
• Fracture of the ribs (cough, trauma)
• Secondaries in the ribs
• lntercostal neuralgias
• Pain is usually well localised, variable in intensity and site, varying
with posture and movement.
• Usually associated with severe local tenderness.

18. INTRA-ABDOMINAL CONDITIONS
• Intra-abdominal conditions can occasionally present as chest pain.
These include the following:
• Acute pancreatitis
• Acute cholecystitis
• Perforated peptic ulcer