What are the next best steps in managing a patient with recurrent chest pain, previously thought to be non-cardiac in nature, with a negative Coronary Computed Tomography Angiography (CCTA) for Coronary Artery Disease (CAD)?

Management of Recurrent Non-Cardiac Chest Pain After Negative CCTA

For patients with recurrent chest pain previously determined to be non-cardiac in nature with a negative CCTA for CAD, referral to a cognitive-behavioral therapist is the most appropriate next step in management. 1

Understanding the Clinical Context

When a patient has:

• Previous episodes of chest pain evaluated by a cardiologist
• Negative CCTA ruling out coronary artery disease
• Pain thought to be muscular in nature
• Recurrent, similar presentations

This clinical picture strongly suggests non-cardiac chest pain (NCCP), which requires a different management approach than cardiac chest pain.

Diagnostic Considerations

Ruling Out Cardiac Causes

• A negative CCTA has an excellent negative predictive value (>95%) for excluding coronary artery disease 1
• CCTA is considered appropriate for evaluating chest pain in patients with low to intermediate probability of CAD 1
• When CCTA shows no evidence of calcified or non-calcified plaque, it is highly unlikely that symptoms are due to UA/NSTEMI of atherosclerotic origin 1

Non-Cardiac Causes to Consider

1. Musculoskeletal causes (most likely in this case)

   • Costochondritis
   • Cervical radiculopathy 1

2. Gastrointestinal causes

   • Gastroesophageal reflux disease (GERD) - most common esophageal cause of NCCP
   • Esophageal motility disorders
   • Esophageal hypersensitivity 1

3. Psychological factors

   • Anxiety
   • Panic disorder
   • Depression
   • Somatoform disorders 1

Management Algorithm

1. First step: Referral to cognitive-behavioral therapy

   • For patients with recurrent, similar presentations of chest pain
   • With no evidence of physiological cause on prior diagnostic evaluation
   • Including negative workup for myocardial ischemia 1

2. Consider gastrointestinal evaluation

   • Reasonable for patients with recurrent chest pain without evidence of cardiac or pulmonary cause 1
   • May include:
     • Upper endoscopy
     • Ambulatory pH testing
     • Esophageal motility studies

3. For suspected musculoskeletal pain

   • Physical therapy referral
   • Anti-inflammatory medications
   • Local treatments

4. Provide reassurance and education

   • Many patients (>50%) with non-cardiac chest pain are not convinced by their negative cardiac diagnosis 2
   • Explain the excellent negative predictive value of CCTA
   • Discuss the benign prognosis regarding mortality

Important Clinical Considerations

• Psychological impact: NCCP significantly reduces quality of life, comparable to or even worse than cardiac chest pain 3
• Recurrence rate: Approximately 50% of patients with NCCP will experience symptom recurrence 3
• Duration: Median duration of ongoing pain is about 5.4 months 2
• Gender differences: Women are twice as likely as men to continue experiencing pain 2

Common Pitfalls to Avoid

1. Repeated cardiac testing despite negative prior evaluations

   • Increases healthcare costs
   • Reinforces illness behavior
   • Does not address underlying cause

2. Dismissing symptoms as "just anxiety"

   • Even if psychological factors are present, the pain is real to the patient
   • Acknowledge the symptoms while providing reassurance

3. Failing to provide adequate explanation

   • Patients need to understand why their pain is not cardiac
   • Uncertainty about diagnosis contributes to psychological strain 3

4. Missing non-cardiac organic causes

   • GERD is present in 50-60% of NCCP cases
   • Esophageal motility disorders account for 15-18% 3

By following this approach, you can effectively manage patients with recurrent non-cardiac chest pain while minimizing unnecessary testing and addressing the underlying causes of their symptoms.