What is the treatment for non-cardiac chest pain?

Treatment of Non-Cardiac Chest Pain

For patients with recurrent non-cardiac chest pain and no evidence of physiological cause after thorough cardiac evaluation, referral to a cognitive-behavioral therapist is the most effective treatment approach. 1

Diagnostic Framework

Before initiating treatment for non-cardiac chest pain (NCCP), it's essential to establish the diagnosis by excluding cardiac causes:

1. Rule out cardiac causes:

   • Complete cardiac workup including ECG, cardiac biomarkers, and stress testing
   • Consider coronary angiography in appropriate cases

2. Identify underlying mechanism:

   • GERD (most common cause)
   • Esophageal dysmotility
   • Functional chest pain (psychological factors)
   • Musculoskeletal causes

Treatment Algorithm Based on Underlying Cause

1. GERD-Related NCCP

• First-line: Proton pump inhibitor (PPI) trial at double-dose for 8 weeks 2, 3
• If responsive: Continue PPI therapy
• If non-responsive: Consider pH monitoring or impedance testing

2. Esophageal Dysmotility

• For spastic disorders:
  • Smooth muscle relaxants (calcium channel blockers, nitrates) for temporary relief 3
  • Consider botulinum toxin injection in refractory cases 3

3. Functional Chest Pain (Non-GERD, Non-Motility)

• First-line: Pain modulators 3, 4

  • Tricyclic antidepressants (e.g., imipramine 50mg at bedtime) 1
  • Selective serotonin reuptake inhibitors (SSRIs)
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs)
  • Trazodone

• Important note: Medical therapy with nitrates, beta-blockers, and calcium channel blockers is NOT recommended for patients with non-cardiac chest pain (Class III recommendation) 1

4. Psychological Interventions

• For all NCCP patients, especially those with psychological comorbidities:
  • Cognitive-behavioral therapy (CBT) 3, 5
  • Hypnotherapy in selected cases 3

Special Considerations

Syndrome X

For patients with syndrome X (angina-like pain, ST-segment depression on exercise testing, but normal coronary arteries):

• Reassurance about excellent prognosis 1
• Consider long-acting nitrates if symptoms persist 1
• If chest pain episodes continue, calcium antagonist or beta-blocker may be added 1

Clinical Pearls and Pitfalls

• Common pitfall: Repeated cardiac testing despite negative evaluations, leading to increased healthcare costs and radiation exposure 1
• Important finding: Depression, anxiety, and gastroesophageal syndromes exceed CAD by almost 10-fold in low-risk chest pain patients 1
• Underutilized approach: Less than 10% of clinicians inquire about psychological factors in chest pain patients with self-reported anxiety 1
• Evidence strength: Cognitive-behavioral approaches have shown a 32% reduction in chest pain frequency over a 3-month period 1

Monitoring and Follow-up

• Regular follow-up to assess treatment response
• Consider alternative or additional therapies if initial treatment fails
• Avoid repeated cardiac testing unless new symptoms or risk factors develop

By implementing this evidence-based approach to NCCP, clinicians can effectively manage symptoms, improve quality of life, and reduce unnecessary healthcare utilization while ensuring that serious cardiac conditions are not missed.