Differential diagnosis of chest pain.

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

The levels of evidence [A-D] supporting the recommendations are defined at the end of the "Major Recommendations" field.

Objectives

Pain caused by myocardial ischaemia or impending infarction must be differentiated from nonischaemic chest pain. Nonischaemic pain may be caused by other severe conditions that require acute treatment, such as pericarditis, aortic dissection, and pulmonary embolism.
Remember that patients at risk can have ischaemic chest pain in addition to nonischaemic chest pain.
Differentiate between stable and unstable angina.

Myocardial Ischaemic Pain

The main feature of myocardial ischaemia (impending infarction) is usually prolonged chest pain. Typical characteristics of the pain include:
- Duration usually over 20 minutes
- Located in the retrosternal area, possibly radiating to the arms (usually to the left arm), back, neck, or the lower jaw
- The pain is described as pressing or heavy or as a sensation of a tight band around the chest; breathing or changing posture does not notably influence the severity of the pain.
- The pain is continuous, and its intensity does not alter
- The symptoms (pain beginning in the upper abdomen, nausea) may resemble the symptoms of acute abdomen. Nausea and vomiting are sometimes the main symptoms, especially in inferoposterior wall ischaemia.
- In inferoposterior wall ischaemia, vagal reflexes may cause bradycardia and hypotension, presenting as dizziness or fainting.
Electrocardiogram (ECG) is the key examination during the first 4 hours after pain onset, but normal ECG does not rule out an imminent infarction.
Markers of myocardial injury (cardiac troponins T and I, creatine kinase-MB mass) start to rise about 4 hours after pain onset. An increase of these markers is diagnostic of myocardial infarction irrespective of ECG findings.
Minor signs of myocardial infarction in ECG, see Table 1 in the original guideline document

Nonischaemic Causes of Chest Pain

For nonischaemic causes of chest pain, see Table 2.
For ECG changes resembling those of a myocardial infarction (MI), see Table 3.

Table 2. Nonischaemic Causes of Chest Pain

Illness/condition	Differentiating symptoms and signs
Reflux oesophagitis, oesophageal spasm	No ECG changes Heartburn Worse in recumbent position, but also while straining, like angina pectoris The most common cause of chest pain
Pulmonary embolism	Tachypnoea, hypoxaemia, hypocarbia No pulmonary congestion on chest x-ray Clinical presentation may resemble hyperventilation. Both arterial oxygen pressure (PaO₂) and partial arterial pressure of carbon dioxide (PaCO₂) decreased. Pain is not often marked. D-dimer assay positive
Hyperventilation	Hyperventilation Syndrome The main symptom is dyspnoea, as in pulmonary embolism. Often a young patient Tingling and numbness of the limbs, dizziness PaCO₂ decreased, PaO₂ increased or normal Secondary Hyperventilation Attributable to an organic illness/cause; acidosis, pulmonary embolism, pneumothorax, asthma, infarction, etc.
Spontaneous pneumothorax	Dyspnoea is the main symptom. Auscultation and chest x-ray
Aortic dissection	Severe pain with changing localization Type A dissection sometimes obstructs the origin of a coronary artery (usually the right) with signs of impending inferoposterior infarction Pulses may be asymmetrical Sometimes broad mediastinum on chest x-ray New aortic valve regurgitation
Pericarditis	Change of posture and breathing influence the pain. A friction sound may be heard. ST-elevation but no reciprocal ST depression
Pleuritis	A stabbing pain when breathing. The most common cause of stabbing pain is, however, caused by prolonged cough
Costochondral pain	Palpation tenderness, movements of chest influence the pain Might also be an insignificant incidental finding
Early herpes zoster	No ECG changes, rash Localized paraesthesia before rash
Ectopic beats	Transient, in the area of the apex
Peptic ulcer, cholecystitis, pancreatitis	Clinical examination (inferior wall ischaemia may resemble acute abdomen)
Depression	Continuous feeling of heaviness in the chest, no correlation to exercise ECG normal
Alcohol-related	A young male patient in a casualty department, inebriated

Table 3. ECG Changes Resembling Those of an MI

ST changes resembling those of acute ischaemia
ST segment elevation	Early repolarization in V1–V3. Seen particularly in athletic men ("athlete's heart") Acute myopericarditis in all leads except V1, aVR. Not resolved with a beta-blocker. Pulmonary embolism – in inferior leads Hyperkalaemia Hypertrophic cardiomyopathy
ST segment depression	Sympathicotonia Hyperventilation Pulmonary embolism Hypokalaemia Digoxin Antiarrhythmics Psychiatric medication Hypertrophic cardiomyopathy Reciprocal ST depression of an inferior infarction in leads V2–V3–V4 Circulatory shock
QRS changes resembling those of Q wave infarction	Hypertrophic cardiomyopathy Wolff-Parkinson-White (WPW) syndrome Myocarditis Blunt cardiac injury Massive pulmonary embolism (QS in leads V1–V3) Pneumothorax Cardiac amyloidosis Cardiac tumours Progressing muscular dystrophy Friedreich's ataxia
ST changes resembling those of a non-Q wave infarction	Increased intracranial pressure – subarachnoid bleed – skull injury Hyperventilation syndrome Post-tachyarrhythmia state Circulatory shock – haemorrhage – sepsis Acute pancreatitis Myopericarditis

Related Evidence

The Acute Cardiac Ischaemia (ACI) diagnostic instrument is effective in the diagnosis of cardiac ischaemia. Other effective technologies include the Acute Cardiac Ischaemia-Time Insensitive Predictive Instrument (ACI-TIPI), the prehospital ECG, the Goldman chest pain protocol, and the ECG exercise test (Selker et al., 1997; DARE-985026, 2000) [A].

Definitions:

Levels of Evidence

Strong research-based evidence. Multiple relevant, high-quality scientific studies with homogenic results.
Moderate research-based evidence. At least one relevant, high-quality study or multiple adequate studies.
Limited research-based evidence. At least one adequate scientific study.
No research-based evidence. Expert panel evaluation of other information.

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