From the Guidelines
A patient with a negative chest pain workup and no evidence of cardiac ischemia or myocardial infarction is most likely experiencing non-cardiac chest pain, which may be due to psychological entities such as somatization or noncardiac chest pain. This diagnosis is supported by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain, which states that most low-risk patients presenting with chest pain do not have life-threatening conditions 1. The guideline also notes that depression, anxiety, and gastroesophageal syndromes are common diagnoses in low-risk chest pain patients without evidence of cardiac disease, and that these conditions can be effectively managed with cognitive-behavioral therapy and medications such as antidepressants and anxiolytics 1.
Some possible causes of non-cardiac chest pain include:
- Musculoskeletal issues
- Gastroesophageal reflux disease (GERD)
- Anxiety
- Other non-life-threatening conditions
Management of non-cardiac chest pain typically involves treating the underlying cause. For example:
- Musculoskeletal pain may be managed with NSAIDs such as ibuprofen 400-600mg three times daily for 7-10 days
- GERD-related pain may be managed with proton pump inhibitors such as omeprazole 20mg daily for 2-4 weeks
- Anxiety-related chest pain may benefit from cognitive behavioral therapy and sometimes SSRIs such as sertraline 50mg daily
It is essential for patients to follow up with their primary care provider within 1-2 weeks after a negative workup to monitor symptoms and adjust management as needed. Patients should also return to the emergency department if they experience recurrent severe pain, shortness of breath, syncope, or other concerning symptoms. Understanding the specific cause of non-cardiac chest pain helps target treatment appropriately and provides reassurance that no serious cardiac condition was identified 1.
From the Research
Diagnosis of Chest Pain
For a patient with a negative chest pain workup, including cardiac catheterization, electrocardiogram, and troponin levels, and no evidence of cardiac ischemia or myocardial infarction, the diagnosis is:
- The patient is considered to be at low risk for cardiac death or myocardial infarction in long-term follow-up 2
- The patient's negative electrocardiogram and biomarker workup for acute coronary syndrome suggests a low risk of cardiac events 2
- Further noninvasive cardiac testing may not be necessary, as the benefits may not outweigh the risks in this patient population 3
Evaluation of Chest Pain
The evaluation of chest pain involves:
- Determining whether the chest pain is cardiac in origin or not 4
- Assessing the likelihood of significant coronary artery disease based on the patient's history, risk factors, and electrocardiogram 4
- Using clinical decision aids, such as the TIMI risk score, GRACE scores, ASPECT, ADAPT, NACPR, and HEART score, to risk-stratify patients and direct the workup and care 5
Management of Chest Pain
The management of chest pain may involve:
- Stress echocardiography or coronary computed tomography angiography to evaluate patients with low- to intermediate-risk acute chest pain 6
- Discharge without stress testing or coronary angiography for patients identified as low-risk using clinical decision aids 5
- Consideration of the patient's individual risk factors and medical history when determining the appropriate course of management 4, 5, 6, 2, 3