The differential diagnosis of chest pain is shown in Figs. 31-1 and 31-2. It is useful to characterize the chest pain as (1) new, acute, and ongoing; (2) recurrent, episodic; and (3) persistent, e.g., for days at a time.
Differential diagnosis of recurrent chest pain. *If myocardial ischemia suspected, also consider aortic valve disease (Chap. 114) and hypertrophic obstructive cardiomyopathy (Chap. 115) if systolic murmur present. TNG, trinitroglycerin.
Differential diagnosis of serious conditions that cause acute chest pain. CK, creatine phosphokinase.
Myocardial Ischemia: Angina Pectoris
Substernal pressure, squeezing, constriction, with radiation often to left arm; usually on exertion, especially after meals or with emotional arousal. Characteristically relieved by rest and nitroglycerin.
Acute Myocardial Infarction
Similar to angina but usually more severe, of longer duration (≥30 min), and not immediately relieved by rest or nitroglycerin (Chaps. 119 and 120). S3 and/or S4 may be present.
May be substernal or lateral, pleuritic in nature, and associated with hemoptysis, tachycardia, and hypoxemia (Chap. 133).
Very severe, in center of chest, a sharp “ripping” quality, radiates to back, not affected by changes in position (Chap. 125). May be associated with weak or absent peripheral pulses.
Sharp, intense, localized to substernal region; often associated with audible crepitus.
Usually steady, crushing, substernal; often has pleuritic component aggravated by cough, deep inspiration, supine position, and relieved by sitting upright; pericardial friction rub often audible (Chap. 116).
Due to inflammation; less commonly tumor and pneumothorax. Usually unilateral, knifelike, superficial, aggravated by cough and respiration.