From the Guidelines
Non-cardiac chest pain is likely due to musculoskeletal issues, gastroesophageal reflux disease (GERD), anxiety, or other non-heart related causes after cardiac conditions have been ruled out. The differential diagnosis for noncardiac causes of acute chest pain is quite broad and includes respiratory, musculoskeletal, gastrointestinal, psychological, and other causes 1. Of these, musculoskeletal causes are the most common, including costochondritis, muscle strain, and potential consequences of recent or occult chest trauma such as rib fracture. Various gastrointestinal causes, commonly esophageal, can present with chest pain, including gastrointestinal reflux and esophageal dysmotility as well as gastritis from either medications or peptic ulcer disease.
Key Considerations
- Treatment typically includes addressing the underlying cause with medications such as proton pump inhibitors (PPIs) like omeprazole 20-40mg daily for 4-8 weeks for GERD-related pain, or NSAIDs like ibuprofen 400-600mg every 6-8 hours for musculoskeletal pain 1.
- Anxiety-related chest pain may respond to cognitive behavioral therapy and sometimes anti-anxiety medications like selective serotonin reuptake inhibitors (SSRIs).
- Lifestyle modifications are important, including avoiding trigger foods for GERD (spicy, fatty, acidic foods), stress reduction techniques, proper posture, and regular exercise.
- Patients should be reassured about the benign nature of their condition while acknowledging that the pain is real and can be managed effectively.
- If symptoms persist or worsen despite treatment, further evaluation may be necessary to identify other potential causes, as evidenced by studies suggesting a substantial prevalence of reflux-induced pain in the non-cardiac chest pain population, possibly representing 30-50% of patients 1.
Management Approach
- A step-wise approach to management, starting with the most common causes and progressing to less common ones, is recommended.
- The use of PPIs and NSAIDs should be guided by the underlying cause of the chest pain, with consideration of the potential benefits and risks of these medications.
- Cognitive behavioral therapy and anti-anxiety medications may be considered for patients with anxiety-related chest pain.
- Lifestyle modifications should be encouraged for all patients, regardless of the underlying cause of their chest pain.
From the Research
Definition and Causes of Non-Cardiac Chest Pain (NCCP)
- Non-cardiac chest pain (NCCP) is defined as recurring, angina-like, chest pain of non-cardiac origin 2
- The most common contributing factor for NCCP is gastroesophageal reflux disease (GERD) 2, 3, 4, 5
- Other underlying mechanisms for symptoms include esophageal motility disorders and functional chest pain of presumed esophageal origin 2, 3
- Psychological comorbidities such as panic disorder, anxiety, and major depression are common in NCCP patients 2, 3, 5
Diagnostic Approach
- The diagnostic esophageal workup starts only after cardiac and pulmonary diseases have been ruled out 2
- A high-dose proton pump inhibitor trial (PPI test) can be used to confirm the diagnosis of GERD-related NCCP 2, 4
- Upper endoscopy, wireless pH capsule, and pH-impedance are used to identify GERD-induced NCCP 3, 4
- High-resolution esophageal manometry is the main tool to identify esophageal motor disorder in non-GERD-related NCCP 3, 4
Treatment Options
- Treatment is tailored according to the cause of NCCP: GERD, esophageal dysmotility, or functional chest pain 3, 4
- Potent antireflux treatment is offered to patients with GERD-related NCCP 3, 4
- Medical, endoscopic, or surgical interventions are considered in esophageal dysmotility 3, 4
- Neuromodulators are prescribed for functional chest pain 2, 3, 4
- Assessment and treatment of psychological comorbidity should be considered in all NCCP patients 2, 3, 5