Chest pain: Working up nonemergent conditions

The differential diagnosis of chest pain remains wide-ranging, even after life-threatening causes have been ruled out. Recurrent chest pain at rest with transient ST-segment elevation is the hallmark of coronary artery spasm; diagnosis is confirmed by angiography. Other cardiac causes include aortic stenosis and hypertrophic cardiomyopathy. Pulmonary hypertension is an often-overlooked cause of dyspnea and chest pain; signs may include a thrill in the second left intercostal space over the pulmonic valve, a right ventricular lift, a loud P₂, elevated jugular venous pulse, tricuspid regurgitation, and a right ventricular S₃. Chest pain may also be caused by collagen vascular disease or gastrointestinal conditions, such as gastroesophageal reflux disease and pancreatitis, which may simulate acute myocardial infarction or aortic dissection.