Differential diagnosis of chest pain.

Code

Quality of Evidence

Definition

High

Further research is very unlikely to change our confidence in the estimate of effect.

Several high-quality studies with consistent results
In special cases: one large, high-quality multi-centre trial

Moderate

Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.

One high-quality study
Several studies with some limitations

Low

Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.

One or more studies with severe limitations

Very Low

Any estimate of effect is very uncertain.

Expert opinion
No direct research evidence
One or more studies with very severe limitations

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 (see the Finnish Medical Society Duodecim guideline "Acute Coronary Syndromes: Unstable Angina Pectoris and Non-ST Segment Elevation Myocardial Infarction [NSTEMI]").

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
- 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
- Continuous with constant intensity
- 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 a normal ECG does not rule out an imminent infarction.
Markers of myocardial injury (cardiac troponins T and I, creatine kinase(CK)-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 (see the Finnish Medical Society Duodecim guideline "Myocardial Infarction").
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 below entitled "Nonischaemic Causes of Chest Pain".
For ECG changes resembling those of a myocardial infarction (MI), see Table below entitled "ECG Changes Resembling Those of an MI")

Table. Nonischaemic Causes of Chest Pain

Illness/Condition	Differentiating Symptoms and Signs
Reflux oesophagitis, oesophageal spasm	No ECG changes Heartburn Worse in recumbent position, and also whilst straining, like angina pectoris The most common cause of chest pain. Be careful to recognize a risk patient who also has ischaemia.
Pulmonary embolism	Tachypnoea, hypoxaemia, hypocarbia No pulmonary congestion on chest x-ray, which is often normal Clinical presentation may resemble hyperventilation. Arterial oxygen pressure (PaO₂) decreased or normal, partial arterial pressure of carbon dioxide (PaCO₂) decreased Pain is not often marked. D-dimer assay positive; negative result excludes pulmonary embolism
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
Spontaneous pneumothorax	Dyspnoea is the main symptom in the initial phase, later dyspnoea on exertion only. 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 chest pain is, however, 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 Rash appears after a couple of days Localized paraesthesia before rash
Ectopic beats	Transient, in the area of the apex, felt also at rest
Peptic ulcer, cholecystitis, pancreatitis	Clinical examination (inferior wall ischaemia may resemble acute abdomen). Be careful to recognize a risk patient who also has coronary heart disease.
Depression	Continuous feeling of heaviness in the chest, no correlation to exercise ECG normal
Alcohol-related	A young or middle-aged male patient in a casualty department in a drunken condition. Remember the possibility of ischaemia.

Table. 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 Resources

Refer to the original guideline document for related evidence, including Cochrane reviews and other evidence summaries.

Definitions:

Classification of the Quality of Evidence

Code	Quality of Evidence	Definition
A	High	Further research is very unlikely to change our confidence in the estimate of effect. Several high-quality studies with consistent results In special cases: one large, high-quality multi-centre trial
B	Moderate	Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate. One high-quality study Several studies with some limitations
C	Low	Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate. One or more studies with severe limitations
D	Very Low	Any estimate of effect is very uncertain. Expert opinion No direct research evidence One or more studies with very severe limitations

GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group 2007 (modified by the EBM Guidelines Editorial Team).

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