From the Guidelines
Chest pain in anxiety patients is a common symptom that can be alarming but is typically not dangerous, and the most effective management approach is a combination of cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) as evidenced by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1. The pain often manifests as sharp, stabbing sensations, tightness, or pressure in the chest that may be accompanied by rapid heartbeat, shortness of breath, and dizziness during anxiety episodes. For immediate relief, slow, deep breathing exercises (inhaling for 4 counts, holding for 2, exhaling for 6) can help reduce symptoms. Grounding techniques like the 5-4-3-2-1 method (identifying 5 things you see, 4 things you feel, 3 things you hear, 2 things you smell, and 1 thing you taste) can also be effective. Some key points to consider in managing chest pain in anxiety patients include:
- Differentiating anxiety-related chest pain from cardiac issues, especially in patients with risk factors, as noted in the 2021 guideline 1
- Recognizing that anxiety-related chest pain typically worsens with stress, may change with position, and often lasts longer than cardiac pain, as discussed in the Circulation journal 1
- Understanding that the prognosis of patients with noncardiac chest pain is largely devoid of cardiac complications, but immediate medical evaluation is necessary if chest pain is accompanied by nausea, radiating pain to the arm or jaw, or occurs with exertion, as highlighted in the Circulation journal 1 For medication management, as-needed benzodiazepines like lorazepam (0.5-1mg) or alprazolam (0.25-0.5mg) can provide quick relief, though these should be used sparingly due to addiction potential. For long-term management, SSRIs such as sertraline (starting at 25mg daily, increasing to 50-200mg) or escitalopram (5-20mg daily) are effective, as supported by the guideline 1. Cognitive behavioral therapy (CBT) is highly recommended as a non-pharmacological approach, with a Cochrane database of psychotherapy revealing a 32% reduction in chest pain frequency for a 3-month interval, as noted in the Journal of the American College of Cardiology 1.
From the Research
Chest Pain in Anxiety Patients
- Chest pain is a common complaint in patients presenting to emergency rooms and ambulatory care clinics, with approximately 80% of patients not having a true cardiopulmonary emergency such as acute coronary syndrome (ACS) 2.
- Anxiety is thought to be present in up to 58% of patients with low-risk chest pain, but often remains undiagnosed, leading to chronic chest pain and ED recidivism 2.
- Emergency Department providers believe that approximately 30% of patients seeking emergency care for chest pain at low risk for ACS have anxiety as a primary problem, yet fewer than half discuss this concern or provide information to help the patient manage anxiety 2.
Prevalence of Anxiety and Depressive Disorders
- Anxiety and depressive disorders are common among patients presenting with chest pain to the ED, with no statistically significant differences between patients with cardiac and non-cardiac chest pain 3.
- The prevalence of anxiety disorders is similar between patients with chest pain of cardiac and non-cardiac origin, with approximately 40% of patients with cardiac chest pain and 38.1% of patients with non-cardiac chest pain having anxiety disorders 3.
- Depressive disorders are also common, with approximately 52.3% of patients with cardiac chest pain and 52.1% of patients with non-cardiac chest pain having depressive disorders 3.
Treatment of Anxiety Disorders
- Benzodiazepines, selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs) are commonly prescribed medications for generalized anxiety disorder (GAD) 4, 5.
- A meta-analytic review found that benzodiazepines are the most effective drug for treating GAD, with a moderate to large effect size, while SSRIs and SNRIs have lower effect sizes 5.
- Cognitive therapy is also an effective first-line treatment for GAD, and can be used in conjunction with medication 4.