Differential Diagnosis for Chest Pain and Palpitations at 14 Weeks Gestation

Life-Threatening Cardiovascular Emergencies

The European Society of Cardiology recommends prioritizing life-threatening cardiovascular emergencies, including acute coronary syndrome, pulmonary embolism, and aortic dissection, in the differential diagnosis of chest pain and palpitations during pregnancy 1, 2
Spontaneous coronary artery dissection is more prevalent in pregnant women than non-pregnant women, with risk factors including smoking, hypertension, hyperlipidemia, older maternal age, diabetes, and positive family history 1, 2
The American College of Cardiology states that diagnostic criteria for acute coronary syndrome remain chest pain, ECG changes, and elevated troponin I, even if pre-eclampsia is present 1, 2
Maternal mortality from acute coronary syndrome is 5-10%, highest peripartum but can occur at any gestational stage 1, 2
The American Thoracic Society notes that clinical indications for pulmonary embolism include dyspnea, pleuritic chest pain, tachycardia, hypoxemia, cough, and sweating 3
D-dimer is inadequate to rule out pulmonary embolism in pregnancy, with sensitivity only 73% and specificity 15% 3
Tachycardia plus dyspnea occurs in >90% of pulmonary embolism patients 4
The American College of Cardiology recommends considering aortic dissection in patients with sudden-onset "ripping" chest pain, often described as "worst chest pain of my life," with radiation to upper or lower back 4

The American College of Cardiology states that supraventricular tachycardia is the most common arrhythmic cause in pregnancy, occurring in 20-44% of pregnancies, and presents with sudden-onset palpitations, chest tightness, and documented tachycardia 5

The American College of Gastroenterology notes that gastroesophageal reflux disease is extremely common in pregnancy due to progesterone-induced lower esophageal sphincter relaxation, and can mimic cardiac chest pain but is typically related to meals 4

The European Society of Cardiology recommends immediate evaluation for severe, persistent pain unrelieved by rest, hemodynamic instability, documented sustained tachycardia with chest pain, and diaphoresis, dyspnea, or hypoxemia accompanying chest pain 1, 4, 6
The American College of Cardiology states that the initial workup must include a 12-lead ECG to assess for ischemic changes, arrhythmias, or prolonged QT, cardiac biomarkers if acute coronary syndrome is suspected, echocardiography to evaluate wall motion abnormalities and structural disease, and thyroid function tests if tachycardia is present 1, 2, 5, 7

The American College of Cardiology recommends performing a focused cardiovascular examination, assessing for pulse differentials, unilateral decreased breath sounds, cardiac murmurs, signs of heart failure, and extremity edema/tenderness, in patients with chest pain during pregnancy 8
The American Society of Anesthesiologists notes that heart rate increases 10-20 bpm in pregnancy, and blood pressure may decrease 10-15 mmHg by 20 weeks, but respiratory rate and oxygen saturation remain unchanged 9
The American College of Radiology recommends obtaining a chest radiograph as the initial imaging study for all pregnant patients with suspected pulmonary embolism or other chest pathology, with a rating of 9/9 "usually appropriate" 10
The American Thoracic Society advises against using D-dimer testing to exclude pulmonary embolism in pregnancy due to inadequate sensitivity and specificity, with documented false negatives in pregnant women with confirmed pulmonary embolism 11

The American College of Cardiology recommends obtaining 12-lead ECG immediately to assess for ischemic changes, arrhythmias, or prolonged QT interval, in patients with suspected acute coronary syndrome 9
The American College of Radiology recommends performing bilateral lower extremity duplex ultrasound as the first step in evaluating suspected pulmonary embolism, with a rating of 8/9 "usually appropriate" 10
The American College of Radiology recommends using CT pulmonary angiography or ventilation-perfusion scintigraphy to evaluate suspected pulmonary embolism, with ratings of 7/9 "usually appropriate" 10
The American Society of Anesthesiologists notes that echocardiography should be performed for unexplained or new cardiovascular signs/symptoms, to evaluate wall motion abnormalities, structural disease, and to assess for aortic dissection 9

The European Society of Cardiology recommends that the essential lab workup for a pregnant woman with chest pain must include cardiac troponin, complete blood count with platelets, comprehensive metabolic panel, and liver function tests, with additional testing guided by clinical presentation 12
High-sensitivity cardiac troponin should be obtained in all pregnant patients with acute chest pain, as diagnostic criteria for ACS remain chest pain, ECG changes, and elevated troponin I even during pregnancy 12
Complete blood count with platelet count is essential to assess for HELLP syndrome and other hematologic complications 12
Hemoglobin and fibrinogen levels help evaluate for bleeding disorders and disseminated intravascular coagulation 12

Serum creatinine, eGFR, and electrolytes are required to assess renal function and identify pre-eclampsia-related complications 12
Lactate dehydrogenase (LDH) and haptoglobin should be measured to evaluate for hemolysis, particularly when HELLP syndrome is suspected 12
Liver function tests are critical as hepatic tenderness suggests hepatic swelling with risk of rupture in hypertensive emergencies 12

NT-proBNP should be obtained if heart failure is suspected, particularly given the risk of peripartum cardiomyopathy which increases with pre-eclampsia 12
sFlt-1/PlGF ratio can predict the short-term absence of pre-eclampsia when the syndrome is clinically suspected, with a ratio of 38 or lower being reassuring 12
Plasma or urinary fractionated metanephrines may be needed to rule out pheochromocytoma in the differential diagnosis 12

Urine albumin-to-creatinine ratio (ACR) is essential for detecting proteinuria associated with pre-eclampsia 12
Urine microscopy should evaluate for red cells, leukocytes, and casts to assess for renal involvement 12
Urine drug screen should be obtained when methamphetamine or cocaine use is suspected, as these are risk factors for hypertensive emergencies 12