INTRODUCTION

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 threat to life are emphasized, including the following six entities: acute coronary syndrome, aortic dissection, effort rupture of the esophagus, perforating peptic ulcer, pulmonary embolus, and tension pneumothorax. In the primary care setting, reports of the etiology of chest pain are consistent, including musculoskeletal (36 to 49 percent), cardiac (15 to 18 percent), gastrointestinal (8 to 19 percent), pulmonary (5 to 10 percent), and psychiatric (8 to 11 percent) [1-4].  

The office and emergency department evaluation of the patient with chest pain are discussed in detail separately. (See "Diagnostic approach to chest pain in adults" and "Evaluation of chest pain in the emergency department".)

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 1) [1-4]. Musculoskeletal causes of chest pain are typically not life-threatening. However, it is important to note that 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 [1]. 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, consistent with a musculoskeletal pain etiology. Certain characteristics of the chest pain or associated symptoms, such as dyspnea, may suggest a non-musculoskeletal 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; positional or pleuritic components are also noted in a variety of visceral processes, particularly those involving the pleura and pericardium.