NewsDec 05 2012
The differential diagnosis of patients presenting with chest pain is extensive, ranging from benign musculoskeletal etiologies to life-threatening cardiac disease. Many of the diseases that cause chest pain are reviewed in detail elsewhere. This topic will discuss the differential diagnosis of chest pain in an approximate order of prevalence seen in primary care practice. Within each subsection, diseases that may pose an immediate life-threat are discussed first, followed by the more common etiologies, and then by other causes of chest pain. Details about the office evaluation of the patient with chest pain are found separately.
CHEST WALL PAIN
Chest wall causes of pain are among the most common etiologies of chest pain seen by primary care clinicians, accounting for 36 percent of episodes in one report (table 1A-B) . Chest wall tenderness may present concomitantly with myocardial ischemia; the latter should be considered first in any patient at risk by age, history, or associated symptoms . Causes of true chest wall pain may be musculoskeletal or related to the skin and sensory nerves.
Musculoskeletal pain — Demographic features, characteristics of the chest pain, and associated symptoms may favor the diagnosis of musculoskeletal chest pain or suggest other causes of chest discomfort (table 2). As an example, the patient may describe a history of repetitive or unaccustomed activity involving the upper trunk or arms. Certain characteristics of the chest pain or associated symptoms may suggest a nonmusculoskeletal origin. (See "Clinical evaluation of musculoskeletal chest pain".)
Musculoskeletal chest pain is often insidious and persistent, lasting for hours to weeks. It is frequently sharp and localized to a specific area (such as the xiphoid, lower rib tips, or midsternum), but may be diffuse and poorly localized. The pain may be positional or exacerbated by deep breathing, turning, or arm movement; the first two, however, are also noted in a variety of visceral processes, particularly those involving the pleura and pericardium.
The proportion of patients with chest pain having a musculoskeletal source varies with the clinical setting. It is more common in ambulatory patients presenting to their primary care clinician than presenting to an emergency department (table 3). It also occurs more frequently among women than men. One study examined the incidence of musculoskeletal chest pain in 122 consecutive patients presenting to an emergency department with chest pain . Of 36 patients diagnosed with costochondritis, 69 percent were women. By comparison, women represented only 31 percent of the presenting patients who did not have a subsequent diagnosis of costochondritis.