Differentials
ST-elevation myocardial infarction (STEMI)
SIGNS / SYMPTOMS
Clinical presentation may not differentiate.
INVESTIGATIONS
ECG will show ST-segment elevation.
Cardiac biomarkers are elevated in both NSTEMI and STEMI.
Unstable angina
SIGNS / SYMPTOMS
Clinical presentation may not differentiate.
INVESTIGATIONS
ECG may show nonspecific ST-segment and T-wave changes.
Cardiac biomarkers are normal.
Aortic dissection
SIGNS / SYMPTOMS
Pain is described as a "tearing" back pain. There may be BP differential between upper and lower extremities.
Aortic dissection often occurs in patients who have collagen vascular disease (i.e., Marfan syndrome).
INVESTIGATIONS
Chest CT angiography with contrast or MR angiography may show the dissection or an intimal flap. CXR may reveal widened mediastinum.
Transesophageal echocardiography may show a dissection depending on the location.
Pulmonary embolism
SIGNS / SYMPTOMS
Patients often present with dyspnea, pleuritic chest pain, cough, or hemoptysis. Hypoxia may be present. Lower limbs should be examined for deep vein thrombosis (enlarged, tender, erythematous calves).
INVESTIGATIONS
For patients with a high probability of pulmonary embolism (PE) on clinical scoring (i.e., PE likely) or an abnormal D-dimer, imaging is required. The multiple-detector computed tomographic pulmonary angiography (CTPA) scanning of the chest is the imaging study of choice for acute pulmonary embolism.
For patients with renal insufficiency or iodinated contrast allergies, ventilation-perfusion scan ± peripheral venous doppler exam are recommended.
Chest CT scan may show central filling defects within the vascular lumen, sharp cutoff of the artery, or a "tram track" appearance of the artery in nonocclusive embolism.
Peptic ulcer disease
SIGNS / SYMPTOMS
Pain is described as burning epigastric pain that occurs hours after meals or with hunger. It often wakes the patient at night and is relieved by food and antacids.
There may be a previous history of reflux or medications that can cause peptic ulcer (i.e., recent use of steroid or nonsteroidal anti-inflammatory drugs).
INVESTIGATIONS
Endoscopy may show ulcers, erosion, or gastropathy.
Acute pericarditis
SIGNS / SYMPTOMS
Pain is relieved by sitting forward. Friction rub or distant heart sounds may be heard on auscultation.
History of a recent cardiac procedure (Dressler syndrome), renal failure, or preceding illness (fever or diarrhea) may be present.
INVESTIGATIONS
ECG may show diffuse ST elevations (although PR elevation in aVR is most specific finding).
Echocardiogram and chest CT scan may show pericardial effusion or thickening of the pericardium. Cardiac MRI is useful and has high sensitivity for detection of pericardial effusion, loculations, and pericardial thickening.
Blood tests may indicate systemic inflammation (e.g., elevated WBC count, elevated erythrocyte sedimentation rate [ESR] or CRP). Renal failure can cause uremic pericarditis.
Esophageal spasm
SIGNS / SYMPTOMS
Usually diagnosed after ruling out other causes of chest pain. A past history of esophageal spasm is typical and there may be a precipitating event.
Pain due to esophageal spasm is often relieved by nitroglycerin, making it difficult to differentiate from cardiac pain.
INVESTIGATIONS
The esophagus may have a corkscrew appearance on barium swallow. This represents simultaneous rings of contraction in the distal esophagus.[72]
Costochondritis
SIGNS / SYMPTOMS
Diagnosis is made on the history or exclusion of other causes. There may be a history of recent or repeated trauma. The pain is typically localized with point tenderness, sharp in nature, and relieved by nonsteroidal anti-inflammatory drugs.
INVESTIGATIONS
There are no specific studies or imaging to diagnose costochondritis.
Panic attack
SIGNS / SYMPTOMS
Most often diagnosed after exclusion of other causes. Patients often have other psychiatric illness. Women are affected more than men. Panic attacks may be situational.
INVESTIGATIONS
No tests or procedures can diagnose anxiety disorders.
Stable ischemic heart disease
SIGNS / SYMPTOMS
Angina pain is recurrent and reproducible with exertion, and is relieved by rest or nitroglycerin.
INVESTIGATIONS
Diagnosis is most often made on history alone. Coronary artery catheterization may show the typical fixed coronary artery luminal wall narrowing.
Intravascular ultrasound during cardiac catheterization may reveal the typical stable plaque of stable angina (calcified, thick fibrous caps) rather than the unstable plaques (lipid-laden, thin caps) that cause acute coronary syndrome.
Myocarditis
SIGNS / SYMPTOMS
There is a wide spectrum of presentation from asymptomatic to cardiogenic shock. Patients may present with a history of recent influenza-like illness associated with arthralgias and malaise. Symptoms of heart failure may be present.
Myocarditis may be idiopathic or caused by infections (viral, bacterial, or fungal), drugs (e.g., chemotherapy agents, antihypertensives, and antiepileptics), and autoimmune disorders (e.g., systemic lupus erythematosus, sarcoidosis, and rheumatoid arthritis).
INVESTIGATIONS
The definitive test is endomyocardial biopsy, which shows lymphocyte infiltration and myocyte necrosis.
Cardiac enzymes or brain natriuretic protein may be elevated.
Leukocytosis, eosinophilia, elevated ESR and CRP, and a rise in serum viral titers are common.
Acute cholecystitis
SIGNS / SYMPTOMS
On physical exam there is constant right upper quadrant pain with or without Murphy sign (inhibition of inspiration due to pain on palpation). There may be a history of gallstones or previous episodes of biliary colic.
INVESTIGATIONS
Ultrasound may show a distended gallbladder and gallstones.[73] If ECG changes accompany cholecystitis, these would most likely include ST elevation.
Boerhaave syndrome
SIGNS / SYMPTOMS
Caused by esophageal rupture with mediastinitis. It typically follows retching or vomiting, aggravated by swallowing. Patients may have subcutaneous emphysema and a hoarse voice.
INVESTIGATIONS
CXR shows pneumomediastinum >90% of the time. Esophagram and CT scan can confirm diagnosis or reveal the condition. CT may show pneumomediastinum and periesophageal air tracks. Esophagram may show an esophageal tear.[74] Endoscopy is not recommended for Boerhaave syndrome.
Brugada syndrome
SIGNS / SYMPTOMS
More common in Asian people and men ages 30 to 50 years. Patients typically present after an episode of polymorphic ventricular tachycardia or a cardiac arrest.
INVESTIGATIONS
ECG shows saddle-shaped ST elevation in leads V1-V3. These changes are associated with complete or incomplete right bundle-branch block and T-wave inversions.
Acute stress cardiomyopathy
SIGNS / SYMPTOMS
Clinical features are similar to NSTEMI and may include chest pain, shortness of breath, and left ventricular wall motion abnormalities. A characteristic feature is that often the clinical state is triggered by a severe extracardiac stressor (e.g., intracranial hemorrhage, pheochromocytoma, exogenous catecholamine administration, severe emotional stress, postoperative stress, sepsis).
INVESTIGATIONS
Often these patients present with ECG changes, cardiac biomarker elevations, and left ventricular dysfunction on cardiac imaging that are indistinguishable from NSTEMI but on coronary angiography will have no obstructive lesion. Coronary angiography remains the definitive test for diagnosis of this condition.
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