Differentials
Angina, unstable
SIGNS / SYMPTOMS
Typical cardiac chest pain is described as a retrosternal pressure or heaviness radiating to the jaw, arm, or neck.
Pain may be intermittent or persistent.
Differentiating risk factors include long-standing hypertension, diabetes, or hypercholesterolemia.
Can be difficult to differentiate from pulmonary embolism (PE) on the basis of signs and symptoms alone.
INVESTIGATIONS
ST segment depression in contiguous leads on ECG.
Normal troponin. These tests may be elevated in PE. Negative diagnostic imaging study for PE.
Critical stenosis of a coronary artery on coronary angiography.
Myocardial infarction, non-ST elevation (NSTEMI)
SIGNS / SYMPTOMS
Presents with central chest pain that is classically heavy in nature, like a sensation of pressure or squeezing.
Examination findings are variable and range from normal to a critically ill patient in cardiogenic shock.
Often difficult to differentiate from pulmonary embolism (PE) in acute setting.
INVESTIGATIONS
ECG does not show ST-elevation, but serum levels of cardiac biomarkers are elevated.
ECG may show nonspecific ischemic changes such as ST depression or T wave inversion.
May see bilateral increased pulmonary vascular congestion on chest radiograph consistent with congestive heart failure.
Elevated troponin. These may also be elevated in the setting of PE.
Regional wall motion abnormality of the left ventricle on echocardiography.
Myocardial infarction, ST-elevation (STEMI)
SIGNS / SYMPTOMS
Presents with central chest pain that is classically heavy in nature, like a sensation of pressure or squeezing.
Examination findings are variable and range from normal to a critically ill patient in cardiogenic shock.
Often difficult to differentiate from pulmonary embolism (PE) in acute setting.
INVESTIGATIONS
STEMI is diagnosed by persistent ST segment elevation in two or more anatomically contiguous ECG leads in a patient with a consistent clinical history.
Elevated troponin; can also be elevated in PE.
Regional wall motion abnormality of the left ventricle on echocardiography.
Critical stenosis of a coronary artery on coronary angiography.
Pneumonia
SIGNS / SYMPTOMS
May be difficult to differentiate on the basis of signs and symptoms.
Cough productive of purulent sputum.
Fever above 102.2°F (39.0°C); generally higher than in pulmonary embolism (PE).[189]
INVESTIGATIONS
White blood cell count normally >11,000/microliter.
Chest x-ray may show a focal opacity and other features of pneumonic consolidation. This can also be seen with PE.
Sputum culture grows an organism known to cause pneumonia.
Negative diagnostic imaging study for PE.
Coronavirus disease 2019 (COVID-19)
SIGNS / SYMPTOMS
Residence in or travel to an area with local transmission of COVID-19, or close contact with a suspected or confirmed case in the 14 days prior to symptom onset.
May be difficult to distinguish clinically from bacterial pneumonia. In addition to fever, cough and dyspnea, other common presenting symptoms include sore throat, myalgia, fatigue and altered sense of taste and/or smell.
Patients with respiratory distress may have tachycardia, tachypnea, or cyanosis accompanying hypoxia.
COVID-19 has been associated with risk for pulmonary embolism.[190]
INVESTIGATIONS
Real-time reverse transcription polymerase chain reaction (RT-PCR): positive for SARS-CoV-2 RNA.
It is not possible to differentiate COVID-19 from other causes of pneumonia on chest imaging.
Bronchitis, acute
SIGNS / SYMPTOMS
More insidious, subacute onset of symptoms than pulmonary embolism (PE).
Diffuse wheezes/rhonchi on pulmonary auscultation.
Cough productive of purulent sputum.
INVESTIGATIONS
Normal chest x-ray. This can also be seen in PE.
Normal D-dimer in the correct clinical setting or a negative diagnostic imaging study for PE.
COPD, acute exacerbation
SIGNS / SYMPTOMS
History of previous/ongoing tobacco use.
Diffuse wheezes on pulmonary auscultation.
Diffuse decrease in breath sounds on pulmonary auscultation.
Increased expiratory phase of the respiratory cycle.
Pulmonary embolism (PE) may be present in 6% to 25% of patients with a COPD exacerbation of unknown cause.[191][192][193]
INVESTIGATIONS
Evidence of hyperinflation, flattened diaphragms, and increased retrosternal air on chest x-ray.
Incompletely reversible reduction in FEV1 and FEV1/FVC on spirometry.
Normal troponin I and T. Normal brain natriuretic peptide.
Normal right and left ventricular function on echocardiography.
Right ventricular (RV) strain with decreased RV function can be seen on echocardiography in patients with pulmonary hypertension secondary to COPD. This can also be seen in PE.
Normal D-dimer in the correct clinical setting or a negative diagnostic imaging study for PE.
Asthma, acute exacerbation
SIGNS / SYMPTOMS
Previous history of asthma/atopy.
Diffuse wheezes on pulmonary auscultation.
Diffusely decreased breath sounds on pulmonary auscultation.
Prolonged expiratory phase of the respiratory cycle.
INVESTIGATIONS
Normal chest radiograph. This can also be seen with PE.
Reversible reduction in peak flow measurement (peak expiratory flow or FEV1).
Normal troponin and normal brain natriuretic peptide.
D-dimer, CT pulmonary angiogram, and ventilation-perfusion (V/Q) scan normal.
Normal D-dimer in the correct clinical setting or a negative diagnostic imaging study for PE.
Congestive heart failure, acute exacerbation
SIGNS / SYMPTOMS
May be difficult to differentiate solely on the basis of signs and symptoms.
More insidious, subacute onset of symptoms than those generally seen with pulmonary embolism (PE).
Orthopnea, paroxysmal nocturnal dyspnea, and documented weight gain are common.
Increased bilateral lower extremity swelling.
Diffuse crackles on pulmonary auscultation.
Elevated jugular venous pressure.
Features of right-sided heart failure can occur in PE.
INVESTIGATIONS
Increased pulmonary vascular congestion on chest radiograph with enlarged cardiac silhouette.
Bilateral alveolar infiltrates on chest radiograph.
Elevated brain natriuretic peptide (BNP). This can also be seen in PE, but PE rarely results in BNP levels >1000 picograms/mL.[194]
Decreased left ventricular function with a decreased ejection fraction on echocardiography.
Normal D-dimer in the correct clinical setting or a negative diagnostic imaging study for PE.
Pericarditis
SIGNS / SYMPTOMS
May be difficult to differentiate on the basis of signs and symptoms.
Chest pain improves when sitting up and worsens when supine.
INVESTIGATIONS
ST segment elevation in all leads on ECG.
Electrical alternans on ECG.
Normal chest radiograph. May see an enlarged cardiac silhouette.
Elevated troponin. This may also be seen with pulmonary embolism (PE).
Pericardial effusion on echocardiography.
Normal D-dimer in the correct clinical setting or a negative diagnostic imaging study for PE.
Tamponade, cardiac
SIGNS / SYMPTOMS
Difficult to differentiate on the basis of signs and symptoms.
The Beck triad of hypotension, muffled heart sounds, and elevated jugular venous pressure are classic features, although are not always present.
Patients often complain of dyspnea and chest pain.
INVESTIGATIONS
Normal chest x-ray. May see an enlarged cardiac silhouette.
Pericardial effusion on echocardiography with evidence of tamponade physiology is diagnostic.
Normal D-dimer in the correct clinical setting or a negative diagnostic imaging study for pulmonary embolism.
Pulmonary hypertension due to chronic thromboembolic disease
SIGNS / SYMPTOMS
History of pulmonary embolism (PE); though some patients diagnosed with pulmonary hypertension due to chronic thromboemblic disease do not report a history of prior PE diagnosis. Bruits over the lung fields (pulmonary flow murmurs) are present in 30% of cases.[195]
More insidious, subacute onset of symptoms than those generally seen with PE.
Documented weight gain.
Bilateral lower extremity swelling.
INVESTIGATIONS
ECG findings can show right axis deviation, P pulmonale, and/or possible right bundle branch block.
Normal D-dimer/chest x-ray.
Ventilation-perfusion lung scintigraphy: one or more segmental-sized or larger unmatched perfusion defects.
Pulmonary angiography: vascular webs or band-like narrowings, intimal irregularities, pouch defects, abrupt and angular narrowing, and proximal obstruction.
Pneumothorax
SIGNS / SYMPTOMS
May be difficult to differentiate on the basis of signs and symptoms.
History of recent trauma to the chest.
Decreased breath sounds unilaterally on pulmonary auscultation.
Hyperresonance on percussion of affected side.
Deviation of the trachea away from the affected lung.
INVESTIGATIONS
Loss of lung markings in the periphery with evidence of lung collapse on chest x-ray.
May see evidence of pneumothorax associated with a rib fracture on chest x-ray.
Normal D-dimer in the correct clinical setting or a negative diagnostic imaging study for pulmonary embolism.
Costochondritis
SIGNS / SYMPTOMS
Presents with insidious onset of anterior chest-wall pain exacerbated by certain movements of the chest and deep inspiration.
Point tenderness on palpation of costochondral joints (particularly the second to the fifth).
INVESTIGATIONS
No specific diagnostic tests.
Normal D-dimer or a negative diagnostic imaging study for pulmonary embolism.
Panic disorder
SIGNS / SYMPTOMS
Sudden-onset anxiety, feeling faint, and palpitations.
Recurrent, discrete period of intense fear/discomfort.
Sense of apprehension can be manifested as fear of death or life-threatening illness.
INVESTIGATIONS
Clinical diagnosis requiring formal psychiatric assessment.
Normal D-dimer or a negative diagnostic imaging study for pulmonary embolism.
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