Chest Pain DDx
Chest pain is one of the highest-yield topics on USMLE Step 1, Step 2 CK, and Step 3.
It is a critical emergency presentation, requiring a systematic approach to differentiate cardiac, pulmonary, gastrointestinal, and musculoskeletal causes.
Understanding the clinical presentation, key diagnostic clues, and management strategies is essential for both the exam and clinical practice.
1. Life-Threatening Causes of Chest Pain
Acute Coronary Syndrome (ACS)
ACS includes unstable angina (UA), non-ST elevation myocardial infarction (NSTEMI), and ST elevation myocardial infarction (STEMI).
Key Features:
Substernal, crushing pain radiating to the left arm or jaw, associated with diaphoresis, nausea, and dyspnea.
Diagnosis:
ECG (ST changes, T-wave inversions), troponins, stress testing, coronary angiography.
Management:
MONA-BASH protocol (Morphine, Oxygen, Nitroglycerin, Aspirin, Beta-blocker, ACE inhibitor, Statin, Heparin).
Aortic Dissection
Key Features:
Sudden, tearing chest pain radiating to the back, asymmetric blood pressures, widened mediastinum on CXR.
Diagnosis:
CT angiography, transesophageal echocardiography (TEE).
Management:
Beta-blockers (labetalol, esmolol), emergent surgery for Type A dissections.
Pulmonary Embolism (PE)
Key Features:
Pleuritic chest pain, dyspnea, tachycardia, hypoxia, hemoptysis, recent immobilization or surgery.
Diagnosis:
Wells criteria, D-dimer, CT pulmonary angiography.
Management:
Anticoagulation (heparin, DOACs), thrombolysis if massive PE.
Tension Pneumothorax
Key Features:
Sudden-onset pleuritic chest pain with dyspnea, tracheal deviation, absent breath sounds, JVD, hypotension.
Diagnosis: Clinical; do not delay treatment for imaging.
Management:
Immediate needle decompression followed by chest tube placement.
Esophageal Rupture (Boerhaave Syndrome)
Key Features:
Severe, sudden-onset retrosternal chest pain, following vomiting, crepitus due to subcutaneous emphysema.
Diagnosis:
Esophagography with water-soluble contrast.
Management:
Broad-spectrum IV antibiotics, surgical repair.
2. Non-Life-Threatening Causes of Chest Pain
Gastroesophageal Reflux Disease (GERD)
Key Features:
Burning, postprandial retrosternal pain, worse when lying down, relieved with antacids.
Diagnosis:
Clinical, pH monitoring if uncertain.
Management:
Lifestyle modification, PPIs, H2 blockers.
Pericarditis
Key Features:
Sharp pleuritic chest pain, worse when supine, relieved by sitting up and leaning forward, pericardial friction rub.
Diagnosis:
ECG (diffuse ST elevations, PR depression), echocardiography for effusion.
Management:
NSAIDs, colchicine (steroids in refractory cases).
Musculoskeletal Pain (Costochondritis, Rib Fracture)
Key Features:
Reproducible pain with palpation, worsened by movement or deep breathing.
Diagnosis:
Clinical.
Management:
NSAIDs, reassurance.
Panic Attack
Key Features:
Sudden chest pain, tachycardia, hyperventilation, paresthesias, feeling of impending doom.
Diagnosis:
Clinical (rule out ACS in first presentation).
Management:
Benzodiazepines for acute attack, SSRIs for long-term management.
3. USMLE High-Yield Takeaways
ACS = Crushing chest pain + ECG/troponin abnormalities → MONA-BASH treatment.
Aortic dissection = Tearing pain radiating to the back + widened mediastinum → CT angiography.
PE = Sudden dyspnea + pleuritic pain + tachycardia → CT pulmonary angiography.
Tension pneumothorax = Absent breath sounds + tracheal deviation → Immediate needle decompression.
Esophageal rupture = Sudden-onset pain + vomiting + subcutaneous emphysema → Contrast esophagography.
GERD = Postprandial burning pain, worsened by lying down → PPIs.
Pericarditis = Pleuritic pain, worse supine, relieved sitting up → NSAIDs + colchicine.
Costochondritis = Reproducible pain on palpation → NSAIDs, reassurance.
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