Differential diagnosis for chest pain

Question 1

Differential diagnosis for chest pain that is not sharp

Answer 1

• Angina
• ST-elevation myocardial infarction
• Non-ST elevation myocardial infarction
• Esophagitis and oesophageal infarction
• Pneumothorax
• Dissecting thoracic aortic aneurysm
• Chest wall pain

Question 2

Angina suggested by:

Answer 2

• 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

Question 3

Angina confirmed by:

Answer 3

• No troponin rise after 12 hours (excludes MI)
• Stress test showing inducible ischemia

Question 4

STEMI suggested by:

Answer 4

• Central chest pain ± radiating to jaw and either arm (left usually)
• Continuous, usually over 30 minutes, not relieved by rest or nitrates

Question 5

STEMI confirmation

Answer 5

• 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

Question 6

NSTEMI

Answer 6

• elevated troponin after 12 hours
• T-wave and ST-segment changes but no ST elevation on serial ECGs

Question 7

Esophagitis and oesophageal spasm suggested by:

Answer 7

• Past episodes of pain when supine, after food
• Relieved by antacids

Question 8

Esophagitis and oesophageal spasm confirmed by:

Answer 8

• No increase in troponin after 12 hours and no ST-segment changes on ECG
• Improvement with antacids
• Esophagitis on endoscopy

Question 9

Pulmonary embolism suggested by:

Answer 9

• Central chest pain
• Abrupt shortness of breath
• Cyanosis
• Tachycardia
• Loud second sound in pulmonary area
• Associated deep vein thrombosis or risk factors such as cancer, recent surgery, immobility

Question 10

Pulmomary embolism confirmed by:

Answer 10

• V/Q scan
• CT pulmoary angiogram

Question 11

Dissecting thoracic aortic aneurysm suggested by:

Answer 11

• Tearing pain often radiating to back and not responsive to analgesia
• Abnormal or absent peripheral pulses
• Early diastolic murmur
• Low blood pressure
• Wide mediastinum on CXR

Question 12

Dissecting thoracic aortic aneurysm confirmed by:

Answer 12

Loss of single clear lumen on CT scan or MRI

Question 13

Causes of chest wall pain

Answer 13

Costochondritis and Tietze’s syndrome, strained muscle or rib injury

Question 14

Chest wall pain suggested by:

Answer 14

Chest pain and localized tenderness of chest wall or chest pain on twisting of neck or thoracic cage

Question 15

Chest wall pain confirmed by:

Answer 15

• No rise in troponin after 12 hours
• No ST-segment changes or T-wave changes serially on ECG
• Response to rest and analgesics.

Question 16

Differential diagnosis for palpitations

Answer 16

• Supraventricular tachycardia
• Episodic heart block; Second-degree or third-degree atrioventricular (AV) block
• Sinus tachycardia
• Atrial fibrilation
• Ventricular ectopy unifocal (benign) or multifocal (may have underlying pathology)
• Menopause
• Thyrotoxicosis
• Pheochromocytoma