Differential Diagnosis

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During the initial assessment of patients with chest pain, it is important that the diagnosis of ACS be considered in concert with other life-threatening conditions. These include aortic dissection, pulmonary embolism, pneumothorax, pericarditis, pericardial tamponade, pneumonia, and esophageal rupture ( Table.45-1). Other significant causes of chest pain include mitral valve prolapse, aortic stenosis, and gastrointestinal conditions, such as perforated ulcer and cholecystitis.

Risk factors for aortic dissection include atherosclerosis, uncontrolled hypertension, coarctation of the aorta, bicuspid aortic valves, aortic stenosis, Marfan syndrome, Ehlers-Danlos syndrome, and pregnancy. The pain of aortic dissection—midline substernal chest pain—is classically described as tearing, ripping, or searing and radiating to the interscapular area of the back. Typically, the pain is at its worst at symptom onset and is often felt both above and below the diaphragm. Symptoms of "secondary" pathologies resulting from arterial branch occlusions—such as stroke, AMI, or limb ischemia—may overshadow the clinical presentation of the dissection and make an accurate diagnosis difficult. Aortic dissection should be considered in the patient with continuing chest pain but without ECG evidence of evolving myocardial infarction.

The most common radiographic finding is mediastinal widening (>75 percent of cases). While aortography remains the "gold standard" in evaluating aortic dissection, both transesophageal echocardiography and high-resolution contrast spiral computed tomography are less invasive techniques that are now widely accepted for this evaluation. Acute dissection is discussed in detail in Chap, 54.

Pulmonary embolism (PE) can manifest in a multitude of presentations including chest pain, syncope, shock, hypoxia, and dyspnea. The pain associated with a PE occurs when inflammation of the parietal pleura overlying the infarction causes chest pain that is generally sharp and related to respiration. Dyspnea, fever, cough, and/or hemoptysis may also be present and the chest wall may be tender to palpation. Patients with massive pulmonary emboli often present with unstable vital signs and the classic presentation of sharp, pleuritic chest pain and dyspnea associated with tachypnea, tachycardia, and hypoxemia.

Spontaneous pneumothorax may occur due to sudden changes in barometric pressure, in smokers or patients with chronic obstructive pulmonary disease, idiopathic pleural bleb disease, in AIDS patients on pentamidine, or in those with other pulmonary pathology. Patients usually complain of a sudden, sharp, lancinating, pleuritic chest pain and dyspnea. If not recognized early, the condition can progress to tension pneumothorax, which is characterized by severe dyspnea, jugular venous distention, tracheal deviation to the contralateral side, and hypotension. Auscultation of the lungs may reveal absence of breath sounds on the ipsilateral side and hyperresonance to percussion but clinical impression alone is unreliable. Diagnosis of a simple pneumothorax is made by chest x-ray.

The pain of acute pericarditis is typically acute, sharp, severe, and constant. It is usually described as substernal, with radiation to the back, neck, or shoulders, and is exacerbated by lying down and by inspiration. It is relieved by leaning forward. The presence of a pericardial friction rub is suggestive of the diagnosis, but absence of a rub does not exclude the diagnosis. The ECG may show diffuse ST-segment elevation and T-wave inversion. Additionally, depression of the PR segment is a highly specific ECG finding for pericarditis. The etiologies of pericarditis are many and must be pursued prior to determining a final disposition and treatment plan.

Mitral valve prolapse (MVP) is the most frequently diagnosed cardiac valvular abnormality and is more commonly diagnosed in women than in men. 34 The discomfort of mitral valve prolapse often occurs at rest, is atypical for myocardial ischemia, and can be associated with dizziness, hyperventilation, anxiety, depression, palpitations, and fatigue. The discomfort may be related to papillary muscle tension, and many patients benefit from the administration of beta-adrenergic blocking agents.35 The more serious complications of MVP are syncope, stroke, infective endocarditis, congestive heart failure, and dysrhythmia. MVP is characterized by a midsystolic click and late systolic murmur detected on cardiac auscultation. Two-dimensional echocardiography is the diagnostic tool of choice and, together with physical exam findings, helps to stratify patients into high- and low-risk categories for developing serious complications. Patients with MVP who do not have a murmur or mitral regurgitation on Doppler have a lower rate of serious complications than those with the following abnormalities on echocardiogram: severe mitral regurgitation, left ventricular enlargement, redundant or thickened mitral valve leaflets, and left atrial enlargement. 35 Palpitations and every type of supraventricular or ventricular dysrhythmia have been associated with MVP.

Any patient who may be in the high-risk category, presenting with concerning signs and symptoms, should be considered for either inpatient evaluation or cardiology consultation and close follow-up as an outpatient.

Pneumonia can produce chest pain or discomfort that is usually sharp and pleuritic. It is usually associated with fever, cough, and hypoxia. Physical exam may reveal rales over the affected lobes, decreased breath sounds, and signs of consolidation, (i.e., bronchial breath sounds). A chest radiograph confirms the diagnosis.

Esophageal rupture (Boerhaave syndrome) is a rare but potentially life-threatening cause of chest pain. Patients classically present with a history of substernal, sharp chest pain of sudden onset that occurs immediately following an episode of forceful vomiting. The patient is usually ill-appearing, dyspneic, and diaphoretic. The physical exam is often normal but may reveal evidence of pneumothorax or subcutaneous air. Chest radiography may be normal or may demonstrate pleural effusion (left more common than right), pneumothorax, pneumomediastinum, pneumoperitoneum and/or subcutaneous air. The diagnosis can be confirmed by a study with water-soluble contrast.

Musculoskeletal or chest wall pain syndromes are diagnoses of exclusion. These syndromes are often characterized by highly localized, sharp, pleuritic and positional chest pain. Pain that is completely reproducible by light to moderate palpation of a discrete area of the chest wall often represents pain of musculoskeletal origin, although musculoskeletal pain commonly accompanies coronary artery disease. Costochondritis is an inflamation of the costal cartilages and/or their sternal articulations and causes chest pain that is variably sharp, dull, and/or increased with respirations. Tietze syndrome is a particular cause of costochondral pain related to fusiform swelling in one or more upper costal cartilages and has a pain pattern similar to that of other costochondral syndromes. Xiphodynia is another inflammatory process that causes sharp, pleuritic chest pain reproduced by light palpation over the xiphoid process. Texidor twinge or precordial catch syndrome is described as a short, lancinating chest discomfort located near the cardiac apex associated with breathing as well as with poor posture and inactivity.

GASTROINTESTINAL DISORDERS It is very difficult to discriminate gastrointestinal disorders from myocardial ischemia. Dyspepsia syndromes, including gastroesophageal reflux disease (GERD), often produce pain described as burning or gnawing, usually in the lower half of the chest and often accompanied by a brackish or acidic taste in the back of the mouth. The recumbent position usually exacerbates the symptoms, and although the pain is usually relieved with antacids, this therapeutic response is also common with myocardial ischemia. Esophageal spasm is often associated with reflux disease and is characterized by a sudden onset of dull, tight, or gripping substernal chest pain, frequently precipitated by the consumption of hot or cold liquids or a large food bolus and often lasting for hours. The pain also responds to sublingual nitroglycerin. Thus, nitroglycerin does not differentiate esophageal spasm from myocardial ischemia.

Peptic ulcer disease is classically characterized as postprandial, dull, boring pain located in the midepigastric region. Patients often describe being awakened from sleep by it. Duodenal ulcer pain is usually relieved after eating food, in contrast to gastric ulcer symptoms, which are often exacerbated by eating. Symptomatic relief is usually achieved by antacid medications. Acute pancreatitis and biliary tract disease present with right-upper-quadrant or epigrastric pain and tenderness but can also present with chest pain.

There are no data to support the practice of a therapeutic intervention as diagnostic challenge. The episodic nature of the pain in many of these symdromes, the very strong potential for placebo effect, and the substantial impact of "negative tests" and reassurance in alleviating anxiety and pain cannot be underestimated. There are no data to prove that chest discomfort relieved by antacids is more likely to be noncardiac in origin than pain that is not so relieved. Conversely, nitroglycerin is a smooth muscle dilator that may afford relief in cases of lower esophageal spasm or biliary colic. As a rule, diagnostic decisions should not be influenced by response to a therapeutic trial. When the history, physical examination, and diagnostic workup point to a gastrointestinal etiology of the pain, the patient may be treated with antacids and H2 blockers, with follow-up referral to an internist or gastroenterologist.

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