Heart Pain (Cardialgia): Or something else? Differential Diagnosis

The following are differential diagnoses of cardiac pain-ordered into cardiac and noncardiac conditions:

In bold, the most common adult differential diagnoses; in square brackets [children, adolescents], the most common child and adolescent differential diagnoses.

A. Cardiac disease (approximately 30% of all cases)

Cardiovascular (I00-I99).

• Acute aortic syndrome (AAS): clinical pictures that can lead to rupture (“tear”) directly or indirectly via aortic dissection (splitting (dissection) of the wall layers of the aorta); differential diagnoses include dissections of the aorta (s. Below), intramural hematomas of the aortic wall (hemorrhage into the aortic wall), and aortic ulcers penetrating by plaque rupture (PAU; ulcerating defect of the inner wall of the aorta).
• Angina pectoris (synonym: stenocardia, German: Brustenge) – seizure-like tightness in the chest (“chest tightness”; sudden pain in the heart area caused by a circulatory disorder of the heart). In most cases, this circulatory disorder is due to stenosis (narrowing) of the coronary vessels; this is caused by coronary artery disease (CAD) or acute coronary syndrome (ACS). ACS, acute coronary syndrome; spectrum of cardiovascular disease ranging from unstable angina (UA) to the two main forms of myocardial infarction (heart attack), non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI))Note: In one study, the so-called typical chest pain for the diagnosis of acute coronary syndrome was shown to have only a 0.54 area under the curve in terms of its discriminatory ability: experienced physicians were 65.8% and novices 55.4%. After completion of treatment, only 15-20% of patients with chest pain were diagnosed with acute coronary syndrome.
• Aortic aneurysm – circumscribed dilatation of the aorta due to congenital or acquired weakening of the arterial wall.
• Aortic dissection (synonym: aneurysm dissecans aortae) – acute splitting (dissection) of the wall layers of the aorta (main artery), with a tear of the inner layer of the vessel wall (intima) and hemorrhage between the intima and the muscle layer of the vessel wall (outer media), in the sense of an aneurysm dissecans (pathological expansion of the artery).
• Acute myocardial ischemia – acute reduced blood flow to the myocardium [children, adolescents].
• Aortic stenosis – obstruction (narrowing) of the outflow tract of the left ventricle.
• Pericardial tamponade – constriction of the heart by the pericardium.
• Hypertrophic cardiomyopathy – weakness of the heart muscle with enlargement of the heart and a tendency to severe arrhythmias, especially under stress.
• Unstable angina pectoris (UA; English unstable angina) – one speaks of an unstable angina pectoris, if the complaints have increased in intensity or duration compared to the previous angina pectoris attacks.
• Cardiomyopathy, peripartum – diseases of the myocardium (heart muscle) around the date of birth [pregnancy].
• Kawasaki syndrome – acute, febrile, systemic disease characterized by necrotizing vasculitis (vascular inflammation) of small and medium-sized arteries.
• Coronary anomalies – anatomical anomalies of the heart disease vessels [children, adolescents].
• Pulmonary embolism* / pulmonary artery embolism (occlusion of one or more pulmonary arteries by a thrombus (blood clot) → pulmonary infarction* (complication of a previous pulmonary embolism) – raise risk factors: Immobilization; malignancies (cancers); medications (estrogens, contraceptives); surgeries; clinical presentation: acute onset of chest pain, sometimes felt as annihilation pain (70-80%),dyspnea (shortness of breath) and tachypnea (increased or Increased or excessive respiratory rate; typical: acute onset; but may also slowly increasing) (80-90%)anxiety, anxiety, vegetative symptoms (eg, sweating) (50%), cough (40%), syncope (brief unconsciousness) (10-20%), hemoptysis (coughing up blood) (10%).
• Mitral valve prolapse – usually congenital malformation of the mitral valve apparatus of the human heart; in this case, the portions of the mitral valve bulge into the left atrium during systole [children, adolescents].
• Myocardial infarction (heart attack)
• Myocarditis (inflammation of the heart muscle)
• Pericardial effusion – accumulation of fluid in the pericardium.
• Pericarditis (inflammation of the pericardium)
• Prinzmetal’s angina – special form of angina pectoris (chest pain) with temporary ischemia (impaired blood flow) of the myocardium (heart muscle), triggered by a spasm (spasm) of one or more coronaries (coronary arteries) (symptoms: pain duration: seconds to minutes; load-independent, especially in the early morning hours); as the worst consequence of ischemia, a myocardial infarction (heart attack) can be triggered.
• Roemheld syndrome – reflex cardiac symptoms caused by gas accumulation in the intestines and stomach, usually due to overeating or flatulent foods; symptomatology: Extrasystoles (heartbeat occurring outside the physiologic heart rhythm), sinus bradycardia (< 60 heartbeats/min), sinus tachycardia (> 100 heartbeats/min), angina pectoris (chest tightness; sudden onset of pain in the cardiac region), dysphagia (difficulty swallowing), syncope (brief loss of consciousness), vertigo (dizziness).
• Stress cardiomyopathy (synonyms: Broken heart syndrome), Tako-Tsubo cardiomyopathy (Takotsubo cardiomyopathy), Tako-Tsubo cardiomyopathy (TTC), Tako-Tsubo syndrome (Takotsubo syndrome, TTS), transient left ventricular apical ballooning) – primary cardiomyopathy (myocardial disease) characterized by short-term impairment of myocardial (heart muscle) function in the presence of overall unremarkable coronary arteries; clinical symptoms: Symptoms of acute myocardial infarction (heart attack) with acute chest pain (chest pain), typical ECG changes, and increase in myocardial markers in the blood; in approx. 1-2% of patients with a suspected diagnosis of acute coronary syndrome are found to have TTC on cardiac catheterization instead of a presumed diagnosis of coronary artery disease (CAD); nearly 90% of patients affected by TTC are postmenopausal women; Increased mortality (death rate) in younger patients, especially men, largely due to increased rates of cerebral hemorrhage (brain bleeding) and epileptic seizures; possible triggers include stress, anxiety, heavy physical work, asthma attack, or gastroscopy (gastroscopy);risk factors for sudden cardiac death in TTC include: Male gender, younger age, prolonged QTc interval, apical TTS type, and acute neurological disorders; long-term incidence for apoplexy (stroke) after five years was significantly higher in patients with Takotsubo syndrome, 6.5%, than in patients with myocardial infarction (heart attack), 3.2% [children, adolescents]
• X syndrome – simultaneous presence of exercise-induced angina, a normal exercise ECG, and angiographically normal coronary arteries (coronary arteries).

* Most common respiratory-dependent pulmonary chest pain.

B. Noncardiac disease (approximately 70% of all cases)

Respiratory System (J00-J99).

• Bronchial asthma [children, adolescents]
• Bronchiectasis (synonym: bronchiectasis)* (irreversible saccular or cylindrical dilatation of the medium-sized airways (bronchi)).
• Bronchitis – inflammation of the bronchi [children, adolescents].
• COPD exacerbation (sudden marked deterioration in the course of COPD disease) with chest pain → think of: cardiac comorbidity (concomitant heart disease).
• Foreign body aspiration – inhalation of foreign bodies.
• Mediastinitis – inflammation in the mediastinum (space in the chest located between the lungs).
• Pleurisy (sicca)* (pleurisy) [children, adolescents].
• Pneumomediastinum (synonym: mediastinal emphysema) – air accumulation in the mediastinum (part of the chest located between the two lungs).
• Pneumonia (pneumonia) (with pleural involvement without effusion* ).
• Pneumothorax* – pulmonary collapse further complicated by a valvular mechanism; primary spontaneous pneumothorax affects males significantly more often than females; male-to-female sex ratio is 7: 1. [Children, adolescents]Note: chest pain more common in pneumonia caused by mycoplasma than otherwise in pneumonia. [Children, Adolescents]
• Pulmonary hypertension (pulmonary hypertension).
• Tracheitis (tracheitis) [children, adolescents]

* Most common respiratory pulmonary chest pain.

Blood-forming organs – immune system (D50-D90).

• Sickle cell disease (sickle cell anemia) → acute chest syndrome [children, adolescents].

Endocrine, nutritional, and metabolic diseases (E00-E90).

• Familial Mediterranean fever (FMF; synonym: familial recurrent polyserositis) – autosomal recessive inherited disease clustered among residents of the eastern Mediterranean region; chronic disease characterized by sporadic episodes of fever with concomitant inflammation of the tunica serosa, resulting in abdominal pain (abdominal pain), thoracic pain, or arthralgia (joint pain).

Skin and subcutaneous (L00-L99).

• Herpes zoster (shingles)

Infectious and parasitic diseases (A00-B99).

• Coxsackie B virus infection-severe respiratory pain [children, adolescents].

Liver, gallbladder and bile ducts – Pancreas (pancreas) (K70-K77; K80-K87).

• Cholangitis (bile duct inflammation).
• Cholelithiasis (gallstones) or biliary colic.
• Cholecystitis (gallbladder inflammation)
• Pancreatitis (inflammation of the pancreas) [children, adolescents].

Mouth, esophagus (esophagus), stomach, and intestines (K00-K67; K90-K93).

• Achalasia of the esophagus (esophagus) – disease in which the lower esophageal sphincter (esophageal sphincter; entrance to the stomach) does not open properly and the motility (mobility) of the muscles of the esophagus is also impaired
• Gastroesophageal reflux disease (synonyms: GERD, gastroesophageal reflux disease; gastroesophageal reflux disease (GERD); gastroesophageal reflux disease (reflux disease); gastroesophageal reflux; reflux esophagitis; reflux disease; reflux esophagitis; peptic esophagitis) – inflammatory disease of the esophagus (esophagitis) caused by the abnormal reflux (reflux) of acid gastric juice and other gastric contents; presents as reflux thoracic pain syndrome [children, adolescents].
• Hollow organ perforation (esophagus, stomach).
• Hiatal hernia – soft tissue hernia, through which the stomach is partially to fully displaced into the chest.
• Esophageal motility disorders – disorder of the movement of the esophagus; leading symptom: dysphagia, which is accompanied by chest pain.
• Esophagitis (inflammation of the esophagus):
  • Eosinophilic esophagitis (EoE); young men with allergic diathesis; leading symptoms: Dysphagia (dysphagia), bolus obstruction (“occlusion by a bite” – usually meat bites), and chest pain [children, adolescents, adults]Note: At least six esophageal biopsies should be obtained from different heights for diagnosis.
  • Infectious esophagitis (most common form: thrush esophagitis; furthermore, viral (herpes simplex type 1 (rarely type 2): cytomegalovirus, HIV (in the context of acute HIV syndrome 2-3 weeks after infection), bacterial (tuberculosis, Mycobacterium avium, streptococci, lactobacilli) and parasitic (Pneumocystis, cryptosporidia, Leishmania)).
  • Physicochemical esophagitis; esp. acid and alkali burns and radiation therapy.
  • “Tablet esophagitis”; most common triggers are antibiotics (esp. doxycycline), bisphosphonates, non-steroidal anti-inflammatory drugs (NSAIDs) and potassium chloride.
  • Systemic diseases that may be associated with esophagitis (eg, collagenoses, Crohn’s disease, pemphigus)
• Esophageal rupture (Boerhaave syndrome) – rupture (“tear”) of the distal, mostly thoracic esophagus after violent vomiting; possibly in alcohol excess.
• Ulcus ventriculi (gastric ulcer)

Musculoskeletal system and connective tissue (M00-M99)

• Chest wall syndrome – neuromusculoskeletal disorders.
• Chest wall tumors, unspecified
• Costochondritis – inflammation of the junctions where the ribs and sternum articulate (inflammation of the costochondral cartilage).
• Fibromyalgia (fibromyalgia syndrome) – syndrome that can lead to chronic pain (at least 3 months) in several regions of the body.
• Cervical spine syndrome
• Intercostal neuralgia – nerve pain (neuralgia) of the chest wall along an intercostal nerve; usually a pulling, persistent pain is present
• Muscular overexertion
• Myositis – inflammation of the muscles.
• Osteochondritis – circumscribed inflammation of bone and cartilage [children, adolescents].
• Rib fracture (rib fracture)
• Shoulder joint arthritis (inflammation of the joint)
• Shoulder joint bursitis (bursitis).
• Tietze syndrome (synonyms: chondroosteopathia costalis, Tietze disease) – rare idiopathic chondropathy of the costal cartilages at the base of the sternum (painful sternal attachments of the 2nd and 3rd ribs) associated with pain and swelling in the anterior thoracic (chest) region [children, adolescents].
• Thoracic wall syndrome – chest pain caused by musculoskeletal changes.
• Cervical disc lesions – disc damage in the cervical spine.

Neoplasms – tumor diseases (C00-D48).

• Bronchial carcinoma (lung cancer)
• Bone metastases (daughter tumors of a cancer).
• Malignant pleural mesothelioma (MPM) – malignant tumor of the pleura (pleura) originating from the mesothelial cells (celomic epithelium); is caused by exposure to asbestos in almost 100% of cases.
• Plasmocytoma (multiple myeloma) – malignant (malignant) systemic disease, which is one of the non-Hodgkin’s lymphomas of B lymphocytes.
• Rib metastases*

Psyche – nervous system (F00-F99; G00-G99)

• Anxiety disorders
• Depression
• Functional thoracic pain; chronic recurrent retrosternal pain (note: not heartburn! ); comorbidities (concomitant conditions): anxiety disorder, depression, and somatization.
• Cardiac neurosis (cardiac phobia, functional cardiac complaints; functional chest pain).
• Mental disorders such as anxiety disorders with panic attacks, panic disorders.
• Cervical disc lesions – disc damage in the cervical spine.

Pregnancy, childbirth and puerperium (O00-O99)

• Amniotic fluid embolism (rare; 2-8/100,000 births) – usually occurs in close temporal relation to childbirth (labor, caesarean section (C-section), up to 48 h postpartum/postpartum)
• Preeclampsia – occurrence of hypertension/high blood pressure, proteinuria/increased excretion of protein with urine during pregnancy, etc., and typical symptoms (headache, persistent visual disturbances, hyperreflexia, and pain in the epigastrium (abdominal region between the costal arch and the navel) or right upper abdomen)

Injuries, poisoning, and other sequelae of external causes (S00-T98).

• Foreign body [children, adolescents]
• Rib fracture (rib fracture) – symptoms: bruise marks, hematomas, pain due to breathing and movement.
• Rib contusion – symptoms: possibly bruise marks, hematomas, respiratory and movement-dependent pain.

Medication

• Drug use
  • Amphetamines e.g., ectasy (synonym: molly; MDMA: 3,4-methylenedioxy-N-methylamphetamine) or similarly acting sympathomimetics; metamphetamines (“crystal meth”)
  • Cannabinoids: cannabis (hashish and marijuana).
  • Cocaine
  • Methylphenidate (individual cases)
  • Opiates
  • Triptans

Operations

• Thoracotomy – surgical opening of the thorax through an intercostal incision (incision in the space between the ribs).

Further

• Intercostal (“between the ribs”) muscle strain due to severe cough* .
• Vitamin D deficiency