Chest Pain Differential

Chest pain is a triage problem before it is a diagnostic label. The same substernal pressure may reflect coronary ischemia, while sharp pleuritic pain may signal pulmonary embolism or pneumothorax. Reflux, chest-wall pain, and anxiety can feel severe, but a reassuring-sounding description does not safely exclude a life-threatening cause. The first question is not, “Which benign condition explains this?” It is, “Which immediately dangerous conditions must be excluded now?” The urgent differential includes acute coronary syndrome (ACS), acute aortic syndrome, pulmonary embolism (PE), tension pneumothorax, oesophageal rupture, and pericarditis complicated by tamponade. Pattern recognition helps set priorities: - ACS may cause pressure, squeezing, heaviness, burning, dyspnoea, nausea, diaphoresis, unusual fatigue, or discomfort in the arm, jaw, back, or upper abdomen. Women, older adults, and people with diabetes are more likely to present without classic exertional substernal pain. - Acute aortic syndrome often begins abruptly with severe chest or back pain. Pulse or blood-pressure differences, a new neurologic deficit, syncope, or evidence of limb, renal, or mesenteric ischemia increase concern, but their absence does not rule it out. - PE commonly...