⚡ QUICK DDX GLANCE — CHEST PAIN

  • STEMI (STE + diaphoresis + cath lab now)

  • NSTEMI/UA (trop up or down, STD/TWI, no emergent cath)

  • Aortic Dissection (tearing, maximal at onset, BP differential)

  • PE (pleuritic + tachycardia + risk factors)

  • Pericarditis (positional, friction rub, diffuse STE + PR depression)

  • Myocarditis (young + viral prodrome + new LV dysfunction)

  • Esophageal Spasm (triggered by swallowing, corkscrew on barium)

  • GERD (burning, postprandial, relieved by antacids)

  • Pneumothorax (sudden, unilateral absent BS, tracheal deviation)

  • Costochondritis (reproducible with palpation, all tests normal)

CHEST PAIN — DDX REFERENCE

Memory hook: Anatomic layers — wall → pleura → vessels → heart → gut MSK (wall) → PTX/Pericarditis/PE (pleura) → Dissection (vessels) → STEMI/NSTEMI/Myocarditis (heart) → GERD/Esophageal spasm (gut)

1. STEMI

  • 🔴 Crushing substernal CP, diaphoresis, radiation jaw/arm, >20 min, not relieved by nitrates

  • 🔬 ECG STE ≥1mm in ≥2 contiguous leads or new LBBB; trop elevated (may be normal early)

  • 💊 Activate cath lab immediately; aspirin 325mg + ticagrelor 180mg; heparin; O2 if sat <90%

  • 💡 Posterior MI (V7-V9) and RV MI (V4R) commonly missed — do right-sided leads if inferior STE

2. NSTEMI / UA

  • 🔴 Substernal CP at rest or minimal exertion; may be atypical (epigastric, jaw); diaphoresis

  • 🔬 Trop elevated (NSTEMI) or negative x2 (UA); ECG: STD, TWI, or normal

  • 💊 Aspirin + heparin + P2Y12; risk stratify TIMI/GRACE; cardiology consult; no emergent cath

  • 💡 Wellens syndrome (biphasic/deep TWI V2-V3) = critical LAD stenosis — do NOT stress test

3. Aortic Dissection

  • 🔴 Tearing/ripping pain maximal at onset, radiates to back; pulse differential; BP differential >20mmHg arm-to-arm

  • 🔬 CXR widened mediastinum; CT angio chest gold standard; negative D-dimer makes unlikely

  • 💊 HR <60 + SBP 100-120 with IV labetalol or esmolol; emergent surgery consult if Type A

  • 💡 Troponin can be elevated if dissection extends to coronaries — do NOT give lytics

4. Pulmonary Embolism

  • 🔴 Pleuritic CP, dyspnea, tachycardia; risk factors (immobility, malignancy, prior VTE, OCP)

  • 🔬 D-dimer to rule out if low pre-test prob; CT-PA gold standard; ECG: S1Q3T3, sinus tach

  • 💊 Anticoagulate immediately (heparin); massive PE → tPA 100mg; submassive → consider CDT

  • 💡 Hemodynamic instability + RV strain = massive PE → thrombolytics before CT if crashing

5. Pericarditis

  • 🔴 Sharp pleuritic CP worse supine, better leaning forward; friction rub on auscultation

  • 🔬 ECG diffuse saddle-shaped STE + PR depression; trop mildly elevated; CRP/ESR elevated

  • 💊 Ibuprofen 600mg TID + colchicine 0.5mg BID x3 months; avoid NSAIDs if post-MI

  • 💡 PR depression in multiple leads + diffuse STE = pericarditis; focal STE = STEMI

6. Myocarditis

  • 🔴 CP + dyspnea in young patient; recent viral illness; may present as new HF or arrhythmia

  • 🔬 Trop elevated; ECG diffuse ST changes or new LBBB; echo new LV dysfunction; MRI gold standard

  • 💊 Supportive; avoid NSAIDs; no exertion; cardiology consult; treat arrhythmias

  • 💡 Young athlete + CP + elevated trop after viral illness = myocarditis until proven otherwise

7. Esophageal Spasm

  • 🔴 Severe substernal CP radiating to back; triggered by swallowing, cold liquids, or stress

  • 🔬 ECG/trop normal; barium swallow "corkscrew"; manometry gold standard

  • 💊 Nitrates or diltiazem; GI referral

  • 💡 Responds to nitroglycerin just like ACS — rule out cardiac first every single time

8. GERD / Esophagitis

  • 🔴 Burning substernal/epigastric pain worse after meals and lying flat; relieved by antacids

  • 🔬 Clinical diagnosis; EGD if alarm features (dysphagia, weight loss, bleeding); ECG/trop normal

  • 💊 PPI BID; dietary modifications; H. pylori test if ulcer concern

  • 💡 GI cocktail relief does NOT rule out ACS — never use as a diagnostic test

9. Pneumothorax

  • 🔴 Sudden pleuritic CP + dyspnea; unilateral decreased breath sounds; tracheal deviation if tension

  • 🔬 CXR visceral pleural line + absent lung markings; tension PTX is a clinical diagnosis

  • 💊 Small/stable → O2 + observation; large → needle decompression 2nd ICS MCL → chest tube

  • 💡 Tension PTX (hypotension + absent breath sounds + JVD + tracheal deviation) → needle immediately, no imaging

10. Costochondritis / MSK

  • 🔴 Reproducible CP with palpation of costochondral junction; no radiation; no diaphoresis

  • 🔬 ECG normal, trop negative; diagnosis of exclusion — rule out cardiac first

  • 💊 NSAIDs, heat, reassurance

  • 💡 Reproducible chest wall tenderness does NOT exclude ACS — 15% of ACS patients have chest wall tenderness