Chest Pain

Christopher M. Walker, MD

DIFFERENTIAL DIAGNOSIS

Common

Acute Myocardial Infarction
Pulmonary Embolism
Pneumothorax
Rib Fracture
Pneumonia
Bronchitis

Less Common

Acute Aortic Syndrome
Pleural Effusion
Diffuse Esophageal Spasm
Gastrointestinal Abnormalities
Aortic Stenosis
Pericardial Disease
Metastatic Disease
Sickle Cell Anemia
Sarcoidosis

Rare but Important

Esophageal Tear
Mediastinitis
Chest Wall Mass
Chest Wall Infection

ESSENTIAL INFORMATION

Key Differential Diagnosis Issues

Chest pain presenting to primary care physician is usually benign
- Usually no radiographic abnormalities
Chest radiograph is initial radiographic examination in emergency department
- Helps to exclude conditions that may mimic acute coronary syndrome

Helpful Clues for Common Diagnoses

Acute Myocardial Infarction
- Chest radiograph normal in 50%
- Pulmonary edema without cardiomegaly in 50%
Pulmonary Embolism
- Chest radiograph abnormal in most patients
  - Cardiomegaly is most common finding
  - Hampton hump and Westermark sign infrequently seen
- CTA: Intraluminal filling defect surrounded by contrast is diagnostic
  - “Doughnut” or “railroad track” sign
- Signs of right heart strain
  - RV/LV chamber size ≥1, leftward bowing of interventricular septum, and reflux into inferior vena cava
Pneumothorax
- Spontaneous
  - Rupture of apical bleb or bulla
  - Young, tall, and thin male smokers
  - Association with emphysema, cystic lung disease, asthma, infection, or lung fibrosis
  - Recurrence is common
- Traumatic pneumothorax due to
  - Chest trauma or mechanical ventilation
Rib Fracture
- ACR states rib radiography not recommended for diagnosis
Pneumonia
- Symptoms of infection
- Lobar or segmental lung consolidation
Bronchitis
- Radiograph usually normal
- ± bronchial wall thickening and mucus plugging

Helpful Clues for Less Common Diagnoses

Acute Aortic Syndrome
- Sudden onset of severe chest/back pain
- Predisposing factors
  - Hypertension, bicuspid aortic valve, and connective tissue disorders
- All 3 conditions have similar classification
  - Stanford type A involves ascending aorta and is treated surgically
  - Stanford type B occurs distal to left subclavian artery and is treated medically
- Life-threatening complications of type A aortic dissection
  - Pericardial tamponade, myocardial infarction, acute aortic insufficiency, and stroke
- Intramural hematoma
  - Diagnose with noncontrast CT
  - Crescent-shaped, high-density thickening of aortic wall
- Penetrating aortic ulcer
  - Atherosclerotic plaque rupture with focal contrast collection within media
  - Common in descending thoracic aorta
  - May propagate and lead to dissection
Pleural Effusion
- Pain usually indicates pleuritis
Diffuse Esophageal Spasm
- Reproduction of pain with tertiary contractions on esophagram
Gastrointestinal Abnormalities
- Occasionally present with chest pain
- Normal chest radiograph or basal atelectasis
- Chest CT may detect unsuspected intraabdominal abnormality
Aortic Stenosis
- Radiograph shows
  - ± aortic valvular calcifications
  - Enlarged ascending aorta with normal heart size
Pericardial Disease
- Pain with pericarditis, pericardial effusion, or metastatic disease
- Pericarditis
  - Thickening and enhancement of pericardium
  - Pericardial fluid
Metastatic Disease
- Bone or lung metastases can cause pain
- Multiple well-circumscribed lung nodules in random distribution
- Lytic or blastic bony lesions
Sickle Cell Anemia
- Acute chest syndrome
  - Vasoocclusive crisis with new lung opacity, ± fever, chest pain, and respiratory symptoms
  - Secondary to infection, infarction, pain episode, or fat embolism
  - Predisposes to pulmonary arterial hypertension through lung fibrosis
- H-shaped vertebral bodies, avascular necrosis of humeral heads, and expanded ribs
- ± posterior mediastinal extramedullary hematopoiesis
Sarcoidosis
- Bilateral hilar and right paratracheal lymphadenopathy
- Perilymphatic distribution of lung nodules (nodules along fissures, subpleural lung, and bronchovascular bundles)

Helpful Clues for Rare Diagnoses

Esophageal Tear
- Occurs with trauma, retching, or iatrogenic injury
- Pneumomediastinum, extravasated oral contrast, and periesophageal fluid collections
Mediastinitis
- Associated with sternotomy, esophageal perforation, or spread of adjacent infection
- Postoperative fluid collections normally resolve in 2-3 weeks
- CT findings
  - Diffuse mediastinal fat stranding and fluid collections
  - Pneumomediastinum
Chest Wall Mass
- Pain occurs with Pancoast tumor and numerous sarcomas
Chest Wall Infection
- Rib sclerosis or periosteal reaction indicates osteomyelitis

Image Gallery

Axial CECT shows dependent ground-glass opacity

with characteristic spared pulmonary lobules. Note right pleural effusion

. Patient had a NSTEMI and 3 vessel disease at angiography.

Axial cardiac CT shows normal wall thickness with subendocardial low-attenuation perfusion defect

occupying less than 50% diameter of the myocardium.

(Left) Axial CECT shows large pulmonary embolism in the left pulmonary artery

with typical “railroad track” sign. Smaller embolism is noted in a segmental left upper lobe pulmonary artery

. It is important to report signs of right heart strain in the setting of pulmonary embolism as it has prognostic implications. (Right) Axial CECT shows a peripheral infarct in the same patient