From the Guidelines
Non-ACS chest pain should be thoroughly evaluated to rule out life-threatening conditions, and treatment should be guided by the underlying cause, with a focus on reducing morbidity, mortality, and improving quality of life. According to the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1, a comprehensive history and physical examination are essential in identifying potential cardiac causes of chest pain. The guideline emphasizes the importance of considering the nature, onset, and duration of chest pain, as well as precipitating and relieving factors, to determine the underlying cause.
When evaluating non-ACS chest pain, it is crucial to consider the potential causes, including gastroesophageal reflux disease (GERD), musculoskeletal problems, anxiety, and pulmonary conditions. Treatment depends on the underlying cause, and may include:
- Proton pump inhibitors like omeprazole 20mg daily for 2-4 weeks for GERD-related pain
- NSAIDs such as ibuprofen 400-600mg three times daily for 5-7 days for musculoskeletal pain
- Relaxation techniques and short-term benzodiazepines like lorazepam 0.5mg as needed for anxiety-related chest pain
The ACR Appropriateness Criteria for chest pain-possible acute coronary syndrome 1 highlights the importance of risk stratification and clinical management in both low-risk and intermediate-risk patients. Noninvasive imaging may be indicated for risk stratification and clinical management, and can help identify patients with a significant ischemic burden who could benefit from coronary revascularization.
A thorough evaluation, including history, physical examination, and possibly ECG, cardiac enzymes, or imaging studies, is necessary before concluding that chest pain is non-cardiac. Even after a non-cardiac diagnosis, persistent or worsening symptoms warrant reassessment, as the presentation of cardiac conditions can sometimes be atypical. It is essential to seek immediate medical attention for any new or concerning chest pain to rule out serious cardiac conditions first.
From the Research
Definition and Diagnosis of Non-ACS Chest Pain
- Noncardiac chest pain (NCCP) is defined as recurrent chest pain that is indistinguishable from ischemic heart pain after excluding a cardiac cause 2.
- The most common esophageal cause of NCCP is gastroesophageal reflux disease (GERD), followed by functional chest pain and esophageal dysmotility 2.
- Diagnostic tests used to identify GERD-induced NCCP include the proton pump inhibitor test, upper endoscopy, wireless pH capsule, and pH-impedance 2.
- High-resolution esophageal manometry is the main tool to identify esophageal motor disorder in non-GERD-related NCCP 2.
Treatment of Non-ACS Chest Pain
- Treatment is tailored according to the cause of NCCP: GERD, esophageal dysmotility, or functional chest pain 2.
- Potent antireflux treatment is offered to patients with GERD-related NCCP 2.
- Medical, endoscopic, or surgical interventions are considered in esophageal dysmotility 2.
- Neuromodulators are prescribed for functional chest pain 2.
- A short course of omeprazole can be used as a diagnostic test in the evaluation of NCCP, with 71% of patients reporting improved chest pain 3.
Challenges in Diagnosing and Treating Non-ACS Chest Pain
- There is no formal recommendation on what diagnostic tests to use to identify underlying diseases after an acute coronary syndrome has been ruled out 4.
- A wide variation in diagnostic processes and treatment recommendations reflects the uncertainty of clinicians on how to approach patients after a cardiac cause was considered unlikely 4.
- Panic and anxiety disorders are rarely considered, and a useful proton pump inhibitor treatment trial to diagnose gastroesophageal reflux disease is infrequently recommended 4.
Effectiveness of Different Treatments
- Intensive antireflux therapy featuring high-dose ranitidine can be effective in patients with noncardiac chest pain and gastroesophageal reflux 5.
- Proton pump inhibitors (PPI) twice daily for at least 8 weeks are recommended for patients with GERD-related NCCP 6.
- Smooth muscle relaxants are only recommended for temporary relief of NCCP with motility disorders 6.
- Botulinum toxin injection of the distal oesophagus may be effective in the treatment of NCCP and spastic oesophageal motility disorders 6.