Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Differential diagnosis of chest pain in adults

James L Meisel, MD, FACP
Daniel Cottrell, MD
Section Editor
Mark D Aronson, MD
Deputy Editor
Lee Park, MD, MPH


The differential diagnosis of patients presenting with chest pain is extensive, ranging from benign musculoskeletal etiologies to life-threatening cardiac disease [1]. 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) [2-5].

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 the adult with chest pain in the emergency department".)


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) [2-5]. 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 [2]. 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.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Jan 2016. | This topic last updated: Feb 25, 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Alpert JS. 'Doctor, I think that I might be having a heart attack'. Am J Med 2015; 128:103.
  2. Klinkman MS, Stevens D, Gorenflo DW. Episodes of care for chest pain: a preliminary report from MIRNET. Michigan Research Network. J Fam Pract 1994; 38:345.
  3. Svavarsdóttir AE, Jónasson MR, Gudmundsson GH, Fjeldsted K. Chest pain in family practice. Diagnosis and long-term outcome in a community setting. Can Fam Physician 1996; 42:1122.
  4. Verdon F, Herzig L, Burnand B, et al. Chest pain in daily practice: occurrence, causes and management. Swiss Med Wkly 2008; 138:340.
  5. Bösner S, Becker A, Haasenritter J, et al. Chest pain in primary care: epidemiology and pre-work-up probabilities. Eur J Gen Pract 2009; 15:141.
  6. Buntinx F, Knockaert D, Bruyninckx R, et al. Chest pain in general practice or in the hospital emergency department: is it the same? Fam Pract 2001; 18:586.
  7. Disla E, Rhim HR, Reddy A, et al. Costochondritis. A prospective analysis in an emergency department setting. Arch Intern Med 1994; 154:2466.
  8. Wise CM. Chest wall syndromes. Curr Opin Rheumatol 1994; 6:197.
  9. Brown CW, Deffer PA Jr, Akmakjian J, et al. The natural history of thoracic disc herniation. Spine (Phila Pa 1976) 1992; 17:S97.
  10. De Maeseneer M, De Mey J, Debaere C, et al. Rib fractures induced by coughing: an unusual cause of acute chest pain. Am J Emerg Med 2000; 18:194.
  11. Harbick S, Frederick R, Ward M, Cummings AJ. Unusual cause of chest pain in a 60-year-old woman. Ann Emerg Med 2000; 35:382.
  12. Rucknagel DL, Kalinyak KA, Gelfand MJ. Rib infarcts and acute chest syndrome in sickle cell diseases. Lancet 1991; 337:831.
  13. Gilden DH, Wright RR, Schneck SA, et al. Zoster sine herpete, a clinical variant. Ann Neurol 1994; 35:530.
  14. National Heart, Lung, and Blood Institute Coronary Artery Surgery Study. A multicenter comparison of the effects of randomized medical and surgical treatment of mildly symptomatic patients with coronary artery disease, and a registry of consecutive patients undergoing coronary angiography. Circulation 1981; 63:I1.
  15. Lusiani L, Perrone A, Pesavento R, Conte G. Prevalence, clinical features, and acute course of atypical myocardial infarction. Angiology 1994; 45:49.
  16. Johnson BD, Shaw LJ, Buchthal SD, et al. Prognosis in women with myocardial ischemia in the absence of obstructive coronary disease: results from the National Institutes of Health-National Heart, Lung, and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation (WISE). Circulation 2004; 109:2993.
  17. Robinson JG, Wallace R, Limacher M, et al. Elderly women diagnosed with nonspecific chest pain may be at increased cardiovascular risk. J Womens Health (Larchmt) 2006; 15:1151.
  18. Lodha A, Mirsakov N, Malik B, Shani J. Spontaneous coronary artery dissection: case report and review of literature. South Med J 2009; 102:315.
  19. Phan A, Shufelt C, Merz CN. Persistent chest pain and no obstructive coronary artery disease. JAMA 2009; 301:1468.
  20. Rosen SD, Uren NG, Kaski JC, et al. Coronary vasodilator reserve, pain perception, and sex in patients with syndrome X. Circulation 1994; 90:50.
  21. Kaski JC, Rosano GM, Collins P, et al. Cardiac syndrome X: clinical characteristics and left ventricular function. Long-term follow-up study. J Am Coll Cardiol 1995; 25:807.
  22. Cannon RO 3rd, Camici PG, Epstein SE. Pathophysiological dilemma of syndrome X. Circulation 1992; 85:883.
  23. Börjesson M, Albertsson P, Dellborg M, et al. Esophageal dysfunction in syndrome X. Am J Cardiol 1998; 82:1187.
  24. STUCKEY D. Cardiac pain in association with mitral stenosis and congenital heart disease. Br Heart J 1955; 17:397.
  25. Lange RA, Hillis LD. Clinical practice. Acute pericarditis. N Engl J Med 2004; 351:2195.
  26. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000; 283:897.
  27. Vilacosta I, Román JA. Acute aortic syndrome. Heart 2001; 85:365.
  28. DeSanctis RW, Doroghazi RM, Austen WG, Buckley MJ. Aortic dissection. N Engl J Med 1987; 317:1060.
  29. Spittell PC, Spittell JA Jr, Joyce JW, et al. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990). Mayo Clin Proc 1993; 68:642.
  30. Nallamothu BK, Saint S, Kolias TJ, Eagle KA. Clinical problem-solving. Of nicks and time. N Engl J Med 2001; 345:359.
  31. Hollander JE, Henry TD. Evaluation and management of the patient who has cocaine-associated chest pain. Cardiol Clin 2006; 24:103.
  32. Bamberg F, Schlett CL, Truong QA, et al. Presence and extent of coronary artery disease by cardiac computed tomography and risk for acute coronary syndrome in cocaine users among patients with chest pain. Am J Cardiol 2009; 103:620.
  33. Hollander JE, Hoffman RS, Gennis P, et al. Prospective multicenter evaluation of cocaine-associated chest pain. Cocaine Associated Chest Pain (COCHPA) Study Group. Acad Emerg Med 1994; 1:330.
  34. Turnipseed SD, Richards JR, Kirk JD, et al. Frequency of acute coronary syndrome in patients presenting to the emergency department with chest pain after methamphetamine use. J Emerg Med 2003; 24:369.
  35. Thygesen K, Alpert JS, White HD, Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. J Am Coll Cardiol 2007; 50:2173.
  36. Davies HA, Jones DB, Rhodes J, Newcombe RG. Angina-like esophageal pain: differentiation from cardiac pain by history. J Clin Gastroenterol 1985; 7:477.
  37. Voskuil JH, Cramer MJ, Breumelhof R, et al. Prevalence of esophageal disorders in patients with chest pain newly referred to the cardiologist. Chest 1996; 109:1210.
  38. Ros E, Armengol X, Grande L, et al. Chest pain at rest in patients with coronary artery disease. Myocardial ischemia, esophageal dysfunction, or panic disorder? Dig Dis Sci 1997; 42:1344.
  39. Fass R, Fennerty MB, Ofman JJ, et al. The clinical and economic value of a short course of omeprazole in patients with noncardiac chest pain. Gastroenterology 1998; 115:42.
  40. Achem SR, Kolts BE, MacMath T, et al. Effects of omeprazole versus placebo in treatment of noncardiac chest pain and gastroesophageal reflux. Dig Dis Sci 1997; 42:2138.
  41. Castell DO, Katz PO. The acid suppression test for unexplained chest pain. Gastroenterology 1998; 115:222.
  42. Furuta GT, Liacouras CA, Collins MH, et al. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology 2007; 133:1342.
  43. Richter JE, Barish CF, Castell DO. Abnormal sensory perception in patients with esophageal chest pain. Gastroenterology 1986; 91:845.
  44. Rao SS, Gregersen H, Hayek B, et al. Unexplained chest pain: the hypersensitive, hyperreactive, and poorly compliant esophagus. Ann Intern Med 1996; 124:950.
  45. Pate JW, Walker WA, Cole FH Jr, et al. Spontaneous rupture of the esophagus: a 30-year experience. Ann Thorac Surg 1989; 47:689.
  46. Guenther M, Wunderlich C, Madisch A, et al. Beans in the pericardium. Lancet 2009; 374:586.
  47. Koyuncu N, Yilmaz S, Soysal S. An unusual cause of chest pain: foreign body in the oesophagus. Emerg Med J 2007; 24:e1.
  48. Jaspersen D. Drug-induced oesophageal disorders: pathogenesis, incidence, prevention and management. Drug Saf 2000; 22:237.
  49. Thomas LR, Baden L, Zaleznik DF. Clinical problem-solving. Chest pain with a surprising course. N Engl J Med 1999; 341:1134.
  50. Majeski J, Durst GG Jr. Geriatric acute perforated appendicitis: atypical symptoms lead to a difficult diagnosis. South Med J 1998; 91:669.
  51. An exploratory report of chest pain in primary care. A report from ASPN. J Am Board Fam Pract 1990; 3:143.
  52. Palla A, Petruzzelli S, Donnamaria V, Giuntini C. The role of suspicion in the diagnosis of pulmonary embolism. Chest 1995; 107:21S.
  53. Yu DR, Miller R, Bray PF. Clinical problem-solving. Through thick and thin. N Engl J Med 1998; 338:1684.
  54. Stein PD, Terrin ML, Hales CA, et al. Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease. Chest 1991; 100:598.
  55. PIOPED II.
  56. Stein PD, Beemath A, Matta F, et al. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med 2007; 120:871.
  57. Stein PD, Fowler SE, Goodman LR, et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 2006; 354:2317.
  58. PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). JAMA 1990; 263:2753.
  59. Marrie TJ. Community-acquired pneumonia. Clin Infect Dis 1994; 18:501.
  60. Edmondstone WM. Chest pain and non-respiratory symptoms in acute asthma. Postgrad Med J 2000; 76:413.
  61. Rizkallah J, Man SF, Sin DD. Prevalence of pulmonary embolism in acute exacerbations of COPD: a systematic review and metaanalysis. Chest 2009; 135:786.
  62. Moore KL. Clinically oriented anatomy, Williams and Wilkins, Baltimore 1985. p.146.
  63. Sadikot RT, Greene T, Meadows K, Arnold AG. Recurrence of primary spontaneous pneumothorax. Thorax 1997; 52:805.
  64. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 9th ed, American College of Surgeons, Chicago 2012.
  65. Gaissert HA, Piyavisetpat N, Mark EJ. Case records of the Massachusetts General Hospital. Case 14-2009. A 36-year-old man with chest pain, dysphagia, and pleural and mediastinal calcifications. N Engl J Med 2009; 360:1886.
  66. Caceres M, Ali SZ, Braud R, et al. Spontaneous pneumomediastinum: a comparative study and review of the literature. Ann Thorac Surg 2008; 86:962.
  67. Alpha-1-antitrypsin deficiency. Usage of alpha-1-proteinase inhibitor concentrate in replacement therapy. A symposium. November 1, 1986, San Diego, California. Proceedings. Am J Med 1988; 84:1.
  68. Eifert GH, Hodson SE, Tracey DR, et al. Heart-focused anxiety, illness beliefs, and behavioral impairment: comparing healthy heart-anxious patients with cardiac and surgical inpatients. J Behav Med 1996; 19:385.
  69. Katon W. Panic disorder and somatization. Review of 55 cases. Am J Med 1984; 77:101.
  70. Wulsin LR, Yingling K. Psychiatric aspects of chest pain in the emergency department. Med Clin North Am 1991; 75:1175.
  71. Fleet RP, Dupuis G, Marchand A, et al. Panic disorder, chest pain and coronary artery disease: literature review. Can J Cardiol 1994; 10:827.
  72. Bass C, Chambers JB, Kiff P, et al. Panic anxiety and hyperventilation in patients with chest pain: a controlled study. Q J Med 1988; 69:949.
  73. Evans DW, Lum LC. Hyperventilation: An important cause of pseudoangina. Lancet 1977; 1:155.
  74. Lipsitz JD, Hsu DT, Apfel HD, et al. Psychiatric disorders in youth with medically unexplained chest pain versus innocent heart murmur. J Pediatr 2012; 160:320.
  75. Worthington JJ 3rd, Pollack MH, Otto MW, et al. Panic disorder in emergency ward patients with chest pain. J Nerv Ment Dis 1997; 185:274.
  76. Lantinga LJ, Sprafkin RP, McCroskery JH, et al. One-year psychosocial follow-up of patients with chest pain and angiographically normal coronary arteries. Am J Cardiol 1988; 62:209.
  77. Lynch P, Galbraith KM. Panic in the emergency room. Can J Psychiatry 2003; 48:361.
  78. Ben Freedman S, Tennant CC. Panic disorder and coronary artery spasm. Med J Aust 1998; 168:376.
  79. Mehta NJ, Khan IA. Cardiac Munchausen syndrome. Chest 2002; 122:1649.
Topic Outline