TOC | Cardiology   

CHEST PAN                                                                                                 

Differential Diagnosis of Chest Pain                                REF:  ACP Medicine Textbook 2005

Cardiac Causes:

Lab Tests:

  • ECG
  • Troponin
  • Treadmill Test
  • Chest xray
  • Echocardiogram (preferred Trans-Esophageal Echocardiogram)
  • Chest CT Scan  

Pulmonary Causes:

Lab Tests:

  • Chest xray
  • Chest CT scan
  • D-Dimers blood test


Digestive GI Causes:
  • Gastroesophageal reflux disease - esophagitis  (see GERD - Reflux Esophagitis )
  • Esophageal spasm or dysmotility (achalasia, diffuse spasm)
    - Achalasia (also called cardiospasm) = neurogenic disorder, leading to aperistalsis and dysfunction of lower esophageal sphincter
    - progressive dysphagia for both liquids and solids and regurgitation
    - chest pain associated with achalasia tends to be common, unresponsive to conventional treatment, unrelated to tests of esophageal motility and manometry, and independent of swallowing symptoms, based on 101 patients with achalasia at one center over 18-year period, 63% had episodic chest pain which tended to improve with age (Gastroenterology 1999 Jun;116(6):1300 in BMJ 1999 Jul 17;319(7203):202)
  • Biliary: Cholelithiasis - cholecystitis, Biliary colic, cholangitis; choledocholithiasis  (see Gallstone-Diseases )
  • Pancreatitis  (see Pancreatitis )
  • Peptic ulcer disease  (see Peptic-Ulcer-Disease )

Lab Tests:

  • EGD
  • Esophagram & UGI xray
  • Esophageal Manometry
  • Abd sonogram or CT scan

Chest Pain of Esophageal Origin    (REF: Cleveland Clinic: Current Clinical Medicine, 2nd ed.2010)

When chest pain occurs in a patient with dysphagia and in whom a structural lesion and all causes of esophagitis have been ruled out by x-ray and endoscopy, a motility disorder is suspected. In diffuse esophageal spasm, chest pain varies in frequency, intensity, and location. Patients report some relief with nitroglycerin or calcium channel blockers. In achalasia, chest pain is reported by approximately 50% of patients and is prominent in the early stages of the disease. The pain is retrosternal, may be aggravated by meals, and is occasionally nocturnal. It may be partially relieved by antacids or calcium channel blockers. The pain is significantly less frequent and less severe in older adults than in younger patients.

Recurrent chest pain, in the absence of dysphagia, is a frequent reason for gastroenterologic consultation from internists and cardiologists. Most patients are men, complaining of retrosternal pain, who have had several visits to the emergency department and in whom cardiac disease has been ruled out. The concept of noncardiac chest pain caused by esophageal disease has been exaggerated. The term esophageal spasm is often used without any objective evidence; the chest pain has sometimes been attributed to nonspecific motor changes noted on manometry or to the nutcracker esophagus. The most frequent cause of chest pain originating from the esophagus is related to acid reflux. Motor disorders account for less than 30% of cases of chest pain studied in a manometry laboratory.


Musculoskeletal Causes:  
  • Chestwall costochondritis or trauma
  • Fibromyalgia or fibrositis
  • Rib fracture
  • Sternoclavicular arthritis
  • Shingles before rash
  • Cervical & thoracic radiculopathy


Psychiatric Causes:
  • Anxiety & panic disorders
  • Hyperventilation
  • Depression
  • Somatization
  • Thought disorders (e.g. fixed delusions)


REF:  Ferri: Ferri's Clinical Advisor 2011


  1. Cardiac: myocardial ischemia/infarction, myocarditis.
  2. Dissecting aortic aneurysm.
  3. Esophageal: spasm, esophagitis, ulceration, neoplasm, achalasia, diverticula, foreign body.
  4. Referred pain from subdiaphragmatic GI structures.
  5. Gastric and duodenal: hiatal hernia, neoplasm, PUD.
  6. Gallbladder and biliary: cholecystitis, cholelithiasis, impacted stone, neoplasm.
  7. Pancreatic: pancreatitis, neoplasm.
  8. Pain originating from skin, breasts, and musculoskeletal structures: herpes zoster, mastitis, cervical spondylosis.
  9. Mediastinal tumors: lymphoma, thymoma.
  10. Pulmonary: neoplasm, pneumonia, pulmonary embolism/infarction.
  11. Psychoneurosis.
  12. Chest pain associated with mitral valve prolapse.


  1. Cardiac: pericarditis, postpericardiotomy/Dressler’s syndrome.
  2. Pulmonary: pneumothorax, hemothorax, embolism/infarction, pneumonia, empyema, neoplasm, bronchiectasis, pneumomediastinum, TB, carcinomatous effusion.
  3. GI: liver abscess, pancreatitis, esophageal rupture, Whipple’s disease with associated pericarditis or pleuritis.
  4. Subdiaphragmatic abscess.
  5. Pain originating from skin and musculoskeletal tissues: costochondritis, chest wall trauma, fractured rib, interstitial fibrositis, myositis, strain of pectoralis muscle, herpes zoster, soft tissue and bone tumors.
  6. Collagen vascular diseases with pleuritis.
  7. Psychoneurosis.
  8. Familial Mediterranean fever.






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