What treatment options are available for a 59-year-old obese female with a history of depression, presenting with recurrent chest pain and shortness of breath, despite negative cardiac workups?

From the Guidelines

For a 59-year-old obese female with depression and recurrent chest pain and shortness of breath despite negative cardiac workups, I strongly recommend a multidisciplinary approach focusing on non-cardiac causes, particularly panic disorder or somatic symptom disorder, as the most effective way to improve morbidity, mortality, and quality of life. This approach is supported by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain, which suggests that psychological entities such as somatization or noncardiac chest pain are common in low-risk patients presenting with chest pain 1. Initial treatment should include:

• Cognitive behavioral therapy (CBT) with a therapist experienced in treating somatic symptoms, scheduled weekly for at least 12 sessions
• Medication options such as an SSRI, like sertraline, starting at 50mg daily and gradually increasing to 100-200mg as needed, to address both depression and anxiety symptoms
• Physical therapy focusing on breathing techniques and gradual exercise, starting with 10-15 minutes of walking daily and slowly increasing
• Weight management through a 500-calorie daily deficit diet and regular exercise
• Sleep hygiene practices should be emphasized These recommendations are based on the most recent and highest quality study available, which highlights the importance of addressing psychogenic factors in patients with recurrent chest pain and negative cardiac workups 1. Regular follow-up every 2-4 weeks initially is essential to monitor progress and adjust treatment as needed. While other studies, such as the 2022 ACC expert consensus decision pathway for integrating atherosclerotic cardiovascular disease and multimorbidity treatment, provide additional guidance on managing cardiovascular disease and multimorbidity, the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline is the most relevant and recent study for this specific patient's condition 1. Additionally, the comparative benefits and harms of antidepressant, psychological, complementary, and exercise treatments for major depression, as reported in the 2016 Annals of Internal Medicine study, support the use of CBT and SSRIs as effective treatments for depression and anxiety symptoms 1. However, the most recent and highest quality study, the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline, takes precedence in guiding treatment decisions for this patient.

From the Research

Treatment Options for Recurrent Chest Pain and Shortness of Breath

Given the patient's history of depression and negative cardiac workups, the following treatment options can be considered:

• Cognitive behavioral therapy (CBT) as a psychotherapy with the highest level of evidence for treating anxiety disorders 2
• Selective serotonin reuptake inhibitors (SSRIs) as first-line drugs for anxiety disorders, which may also help with depression 2, 3
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) as an alternative to SSRIs 2
• Benzodiazepines, such as alprazolam, for short-term use, but with caution due to the risk of physical dependency and potential for exacerbating depression 4, 3, 5

Considerations for Treatment

When developing a treatment plan, the following factors should be considered:

• Efficacy of the treatment option
• Potential adverse effects, such as orthostatic hypotension and weight gain with tricyclic antidepressants and monoamine oxidase inhibitors 4
• Risk of physical dependency with benzodiazepines 4, 3
• Potential for interactions with other medications, such as codeine 6
• Patient preference and history of depression 5

Monitoring and Follow-up

Regular monitoring and follow-up are crucial to assess the patient's response to treatment and adjust the treatment plan as needed. This includes:

• Regular check-ins with the patient to assess symptoms and potential side effects
• Adjusting medication dosages or switching to alternative treatments if necessary
• Considering combination therapy, such as adding a benzodiazepine to an antidepressant, but with caution and careful monitoring 5