Differentials
Stable angina
SIGNS / SYMPTOMS
Pain occurs only in context of exertion or emotional stress, not worsening over time, and relieved by nitrates or rest.
INVESTIGATIONS
ECG may be normal in the absence of pain but may show ST depression during episodes of angina or on stress testing.
Prinzmetal (variant or vasospastic) angina
SIGNS / SYMPTOMS
Typically occurs without provocation and usually resolves spontaneously or with rapid-acting nitrate.[105][106]
May be precipitated by emotional stress, hyperventilation, exercise, or a cold environment.[105][106][107]
Most episodes occur early in the morning.[105][106]
May be younger and/or smoker.[108]
Calcium-channel blockers suppress symptoms (beta-blockers do not suppress symptoms).[107]
INVESTIGATIONS
ST elevation during acute episode.[106]
Coronary angiography (invasive or noninvasive) excludes severe obstructive coronary artery disease but may show spasm.[106] (Fixed lesions and spasm may coexist.)
Nonpharmacologic provocative tests (e.g., cold pressor or hyperventilation) or pharmacologic (e.g., acetylcholine) under supervision and in absence of contraindications to provocative testing (left main disease, advanced 3-vessel disease, presence of high-grade obstructive lesions, significant left-ventricular systolic dysfunction, advanced heart failure) may be diagnostic when invasive assessment is not helpful.[106]
Non-ST-elevation myocardial infarction
SIGNS / SYMPTOMS
Clinical presentation may be indistinguishable.
INVESTIGATIONS
ECG may be normal or show ST depression or T wave inversion. Cardiac biomarkers (troponin I and T) are elevated.
ST-elevation myocardial infarction
SIGNS / SYMPTOMS
Clinical presentation may be indistinguishable.
INVESTIGATIONS
ECG shows persistent ST elevation in 2 or more leads. Cardiac biomarkers (troponin I and T) are elevated.
Congestive heart failure
SIGNS / SYMPTOMS
Breathlessness, orthopnea, tachycardia, and peripheral edema are usually predominant. Chest pain may occur if coronary perfusion is poor.
INVESTIGATIONS
Echocardiogram may show reduced left ventricular ejection fraction or signs of diastolic dysfunction with normal left ventricular ejection fraction.
CXR may show congestion, cardiomegaly, or pleural effusion.
B-type natriuretic peptide: elevated.
Chest wall pain
SIGNS / SYMPTOMS
Onset often insidious, and may be history of repetitive movement or minor trauma. Pain may be reproduced on palpation or movement. Not improved with rest or nitrates but may be relieved by local injection of lidocaine.
INVESTIGATIONS
CXR or bone scan may show skeletal pathology such as rib fracture, osteoarthritis, or metastatic tumor. Diagnosis of soft tissue lesions is clinical.
Pericarditis
SIGNS / SYMPTOMS
Recent myocardial infarction, renal failure, chest irradiation, or associated connective tissue disease.
Pain relieved by sitting up and leaning forward and is worse when lying supine. If pleuropericarditis, the pain may be worse or present only on inspiration.
Pericardial rub may be heard.
INVESTIGATIONS
ECG: concave ST elevation in all leads except aVR; PR segment depression.
Echo: may show minimal pericardial effusion, but is frequently normal.
Myocarditis
SIGNS / SYMPTOMS
Patients often have a recent history of influenza-like illness or underlying autoimmune condition such as systemic lupus erythematosus.
They are likely to be young and often do not have risk factors for coronary artery disease.
Myocarditis is more likely to present with symptoms of cardiac failure than with chest pain.
INVESTIGATIONS
ECG changes and cardiac biomarkers can mimic myocardial infarction.
Inflammatory markers (ESR and CRP) and autoimmune assays may be elevated.
Test of choice is cardiac MRI, with delayed enhancement imaging showing an epicardial or midmyocardial involvement.
Aortic dissection
SIGNS / SYMPTOMS
Patients typically present with tearing chest pain, notably between the shoulder blades.
They can be in considerable distress and hemodynamically unstable.
Peripheral pulses may be unequal or absent distally.
INVESTIGATIONS
CXR: may show wide mediastinum.
ECG may be unremarkable, show sinus tachycardia, or show ST-segment changes if the dissection extends proximally and involves the coronary ostium.
A CT of chest and abdomen with intravenous contrast showing the presence of a dissection flap and a true lumen and false lumen is diagnostic for aortic dissection.
A transesophageal echocardiogram may also show the dissection flap with the true and false lumens.
Pulmonary embolism
SIGNS / SYMPTOMS
Recent surgery, immobilization, prolonged air travel, or cancer.
Acute shortness of breath, pleuritic chest pain, or syncope.
Hypoxia, cyanosis, elevated jugular venous pressure with hypotension and clear lung fields.
INVESTIGATIONS
ECG: sinus tachycardia, right bundle branch block, S1Q3T3 pattern.
CXR: oligemic and hyperlucent lung fields, wedge-shaped infarct if pulmonary infarction.
Ventilation-perfusion scan: pulmonary embolism is likely when an area of ventilation is not perfused.
CT angiogram: reveals pulmonary embolism/thrombus.
Pleuritis
SIGNS / SYMPTOMS
Recent viral infection or prodrome of infection.
Chest pain worse with inspiration.
Audible pleuritic rub.
INVESTIGATIONS
CXR: may show resolving pneumonia.
Pneumothorax
SIGNS / SYMPTOMS
Patients present with sudden onset of pleuritic chest discomfort and shortness of breath.
Tachycardia, hypotension, and cyanosis suggest a tension pneumothorax.
Known underlying medical conditions that predispose to pneumothorax, such as COPD, connective tissue disease, or recent chest trauma, may support this diagnosis.
INVESTIGATIONS
CXR shows a visceral pleural line.
Perforated abdominal viscus
SIGNS / SYMPTOMS
History of previous peptic ulcer disease, diverticulitis, or recent bowel biopsy.
Typically presents with abdominal pain. Chest pain is referred but may be mistaken for cardiac origin.
Abdominal examination shows localized tenderness and, in cases of peritonitis, generalized tenderness.
INVESTIGATIONS
Erect CXR and abdominal series: gas under the diaphragm.
CT abdomen: confirm the presence of free gas within the abdomen and peritoneal cavity.
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