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Guideline:

Differential diagnosis of chest pain

National Guideline Clearinghouse (NGC). Guideline summary: Differential diagnosis of chest pain In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): cited 2001 May 4 (revised 2008 May 16). Available: http://www.guideline.gov.


Bibliographic Source(s)

  • Finnish Medical Society Duodecim. Differential diagnosis of chest pain. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki Finland: Wiley Interscience. John Wiley & Sons; 2008 May 16 [Various].

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Finnish Medical Society Duodecim. Differential diagnosis of chest pain. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki Finland: Wiley Interscience. John Wiley & Sons; 2004 Sep 14 [Various].

Guideline Category

Diagnosis

Intended Users

Health Care Providers
Physicians

Guideline Objective(s)

Evidence-Based Medicine Guidelines collect summarize and update the core clinical knowledge essential in general practice. The guidelines also describe the scientific evidence underlying the given recommendations.

Target Population

Individuals with chest pain

Interventions and Practices Considered

Differential Diagnosis of Chest Pain

  1. Recognizing typical characteristics of myocardial ischemic pain
    • Electrocardiography (ECG) as key examination
    • Measurement of markers of myocardial injury (cardiac troponins T and I creatine kinase [CK]-MB mass)
    • Recognizing minor ECG changes suggestive of myocardial infarction (MI)
  2. Recognizing non-ischemic causes of chest pain
    • Recognizing ECG changes resembling those of an MI

Major Outcomes Considered

Not stated

Methods Used to Collect/Select Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

The evidence reviewed was collected from the Cochrane database of systematic reviews and the Database of Abstracts of Reviews of Effectiveness (DARE). In addition the Cochrane Library and medical journals were searched specifically for original publications.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Classification of the Quality of Evidence

CodeQuality of EvidenceDefinition
AHighFurther research is very unlikely to change our confidence in the estimate of effect.
  • Several high-quality studies with consistent results
  • In special cases: one large high-quality multi-centre trial
BModerateFurther research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.
  • One high-quality study
  • Several studies with some limitations
CLowFurther research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.
  • One or more studies with severe limitations
DVery LowAny estimate of effect is very uncertain.
  • Expert opinion
  • No direct research evidence
  • One or more studies with very severe limitations

GRADE (Grading of Recommendations Assessment Development and Evaluation) Working Group 2007 (modified by the EBM Guidelines Editorial Team).

Methods Used to Analyze the Evidence

Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Peer Review

Description of Method of Guideline Validation

Not stated

Major Recommendations

Objectives

  • Pain caused by myocardial ischaemia or impending infarction must be differentiated from nonischaemic chest pain. Nonischaemic pain may be caused by other severe conditions that require acute treatment such as pericarditis aortic dissection and pulmonary embolism.
  • Remember that patients at risk can have ischaemic chest pain in addition to nonischaemic chest pain.
  • Differentiate between stable and unstable angina (see the Finnish Medical Society Duodecim guideline "Acute Coronary Syndromes: Unstable Angina Pectoris and Non-ST Segment Elevation Myocardial Infarction [NSTEMI]").

Myocardial Ischaemic Pain

  • The main feature of myocardial ischaemia (impending infarction) is usually prolonged chest pain. Typical characteristics of the pain include:
    • Duration usually over 20 minutes
    • Located in the retrosternal area possibly radiating to the arms (usually to the left arm) back neck or the lower jaw
    • Described as pressing or heavy or as a sensation of a tight band around the chest; breathing or changing posture does not notably influence the severity of the pain
    • Continuous with constant intensity
    • Symptoms (pain beginning in the upper abdomen nausea) may resemble the symptoms of acute abdomen. Nausea and vomiting are sometimes the main symptoms especially in inferoposterior wall ischaemia.
  • In inferoposterior wall ischaemia vagal reflexes may cause bradycardia and hypotension presenting as dizziness or fainting.
  • Electrocardiogram (ECG) is the key examination during the first 4 hours after pain onset but a normal ECG does not rule out an imminent infarction.
  • Markers of myocardial injury (cardiac troponins T and I creatine kinase(CK)-MB mass) start to rise about 4 hours after pain onset. An increase of these markers is diagnostic of myocardial infarction irrespective of ECG findings (see the Finnish Medical Society Duodecim guideline "Myocardial Infarction").
  • Minor signs of myocardial infarction in ECG see Table 1 in the original guideline document.

Nonischaemic Causes of Chest Pain

  • For nonischaemic causes of chest pain see Table below entitled "Nonischaemic Causes of Chest Pain".
  • For ECG changes resembling those of a myocardial infarction (MI) see Table below entitled "ECG Changes Resembling Those of an MI")

Table. Nonischaemic Causes of Chest Pain

Illness/ConditionDifferentiating Symptoms and Signs
Reflux oesophagitis oesophageal spasm
  • No ECG changes
  • Heartburn
  • Worse in recumbent position and also whilst straining like angina pectoris
  • The most common cause of chest pain. Be careful to recognize a risk patient who also has ischaemia.
Pulmonary embolism
  • Tachypnoea hypoxaemia hypocarbia
  • No pulmonary congestion on chest x-ray which is often normal
  • Clinical presentation may resemble hyperventilation.
  • Arterial oxygen pressure (PaO2) decreased or normal partial arterial pressure of carbon dioxide (PaCO2) decreased
  • Pain is not often marked.
  • D-dimer assay positive; negative result excludes pulmonary embolism
HyperventilationHyperventilation Syndrome
  • The main symptom is dyspnoea as in pulmonary embolism.
  • Often a young patient
  • Tingling and numbness of the limbs dizziness
  • PaCO2 decreased PaO2 increased or normal
Secondary Hyperventilation
  • Attributable to an organic illness/cause; acidosis pulmonary embolism pneumothorax asthma
Spontaneous pneumothorax
  • Dyspnoea is the main symptom in the initial phase later dyspnoea on exertion only.
  • Auscultation and chest x-ray
Aortic dissection
  • Severe pain with changing localization
  • Type A dissection sometimes obstructs the origin of a coronary artery (usually the right) with signs of impending inferoposterior infarction
  • Pulses may be asymmetrical
  • Sometimes broad mediastinum on chest x-ray
  • New aortic valve regurgitation
Pericarditis
  • Change of posture and breathing influence the pain.
  • A friction sound may be heard.
  • ST-elevation but no reciprocal ST depression
Pleuritis
  • A stabbing pain when breathing. The most common cause of stabbing chest pain is however prolonged cough
Costochondral pain
  • Palpation tenderness movements of chest influence the pain
  • Might also be an insignificant incidental finding
Early herpes zoster
  • No ECG changes rash
  • Rash appears after a couple of days
  • Localized paraesthesia before rash
Ectopic beats
  • Transient in the area of the apex felt also at rest
Peptic ulcer cholecystitis pancreatitis
  • Clinical examination (inferior wall ischaemia may resemble acute abdomen). Be careful to recognize a risk patient who also has coronary heart disease.
Depression
  • Continuous feeling of heaviness in the chest no correlation to exercise
  • ECG normal
Alcohol-related
  • A young or middle-aged male patient in a casualty department in a drunken condition. Remember the possibility of ischaemia.

 

Table. ECG Changes Resembling Those of an MI

ST Changes Resembling Those of Acute Ischaemia
ST segment elevationEarly repolarization in V1–V3. Seen particularly in athletic men ("athlete's heart")
Acute myopericarditis in all leads except V1 aVR. Not resolved with a beta-blocker.
Pulmonary embolism – in inferior leads
Hyperkalaemia
Hypertrophic cardiomyopathy
ST segment depressionSympathicotonia
Hyperventilation
Pulmonary embolism
Hypokalaemia
Digoxin
Antiarrhythmics
Psychiatric medication
Hypertrophic cardiomyopathy
Reciprocal ST depression of an inferior infarction in leads V2–V3–V4
Circulatory shock
QRS changes resembling those of Q wave infarctionHypertrophic cardiomyopathy
Wolff-Parkinson-White (WPW) syndrome
Myocarditis
Blunt cardiac injury
Massive pulmonary embolism (QS in leads V1–V3)
Pneumothorax
Cardiac amyloidosis
Cardiac tumours
Progressing muscular dystrophy
Friedreich's ataxia
ST changes resembling those of a non-Q wave infarctionIncreased intracranial pressure–subarachnoid bleed – skull injury
Hyperventilation syndrome
Post-tachyarrhythmia state
Circulatory shock – haemorrhage – sepsis
Acute pancreatitis
Myopericarditis

Related Resources

Refer to the original guideline document for related evidence including Cochrane reviews and other evidence summaries.

Definitions:

Classification of the Quality of Evidence

CodeQuality of EvidenceDefinition
AHighFurther research is very unlikely to change our confidence in the estimate of effect.
  • Several high-quality studies with consistent results
  • In special cases: one large high-quality multi-centre trial
BModerateFurther research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.
  • One high-quality study
  • Several studies with some limitations
CLowFurther research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.
  • One or more studies with severe limitations
DVery LowAny estimate of effect is very uncertain.
  • Expert opinion
  • No direct research evidence
  • One or more studies with very severe limitations

GRADE (Grading of Recommendations Assessment Development and Evaluation) Working Group 2007 (modified by the EBM Guidelines Editorial Team).

Clinical Algorithm(s)

None provided

Type of Evidence supporting the Recommendations

Concise summaries of scientific evidence attached to the individual guidelines are the unique feature of the Evidence-Based Medicine Guidelines. The evidence summaries allow the clinician to judge how well-founded the treatment recommendations are.

Potential Benefits

Appropriate differential diagnosis of chest pain

Potential Harms

Not stated

Description of Implementation Strategy

An implementation strategy was not provided.

IOM Care Need

Getting Better
Staying Healthy

IOM Domain

Effectiveness

Bibliographic Source(s)

  • Finnish Medical Society Duodecim. Differential diagnosis of chest pain. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki Finland: Wiley Interscience. John Wiley & Sons; 2008 May 16 [Various].

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

Finnish Medical Society Duodecim

Guideline Committee

Editorial Team of EBM Guidelines

Composition of Group that Authored the Guideline

Primary Author: Editors

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Finnish Medical Society Duodecim. Differential diagnosis of chest pain. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki Finland: Wiley Interscience. John Wiley & Sons; 2004 Sep 14 [Various].

Guideline Availability

This guideline is included in "EBM Guidelines. Evidence-Based Medicine" available from Duodecim Medical Publications Ltd PO Box 713 00101 Helsinki Finland; e-mail: info@ebm-guidelines.com; Web site: www.ebm-guidelines.com.

Availability of Companion Documents

None available

Patient Resources

None available

NGC STATUS

This summary was completed by ECRI on August 28 2001. The information was verified by the guideline developer as of October 26 2001. This summary was updated by ECRI on April 2 2004 October 1 2004 and most recently on February 21 2005. This summary was updated by ECRI Institute on September 30 2008.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions.

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop produce approve or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies relevant professional associations public or private organizations other government agencies health care organizations or plans and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC AHRQ and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC AHRQ or its contractor ECRI Institute and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.

Details

0

FDA Warning

Category:
Cardiology, Critical Care, Emergency Medicine, Family Practice, Internal Medicine
Conditions:
Chest pain (ischemic nonischemic)
Published:
2001 May 4 (revised 2008 May 16)
Endorsed by:
Finnish Medical Society Duodecim