How should a clinician respond to a 35-year-old man with chest pain after exercise who is told it's probably anxiety?

Comprehensive Evaluation Required for Chest Pain in Young Adults, Not Just "Anxiety"

A clinician should never dismiss chest pain as "probably anxiety" without first conducting a thorough cardiac evaluation, as this could miss potentially life-threatening conditions in a 35-year-old man with exercise-induced chest pain.

Initial Approach to Chest Pain Evaluation

• A focused cardiovascular examination should be performed initially to aid in diagnosing potentially serious causes of chest pain (e.g., acute coronary syndrome, aortic dissection, pulmonary embolism) 1
• Exercise-induced chest pain in a young adult requires careful evaluation as it may represent myocardial ischemia, even in patients without traditional risk factors 1
• Cultural competency training can help address potential biases that might lead to premature dismissal of symptoms as anxiety, particularly in diverse patient populations 1

Diagnostic Workup Required

• At minimum, patients with exercise-induced chest pain should have an ECG and chest radiograph to help rule out cardiac and pulmonary causes 2
• Patients with exertional chest pain, ECG abnormalities, or cardiac risk factors should have further evaluation with troponin levels and cardiac stress testing 2, 3
• Physical examination findings that suggest cardiac causes include tachycardia, abnormal heart sounds, or murmurs, though the exam may be normal in uncomplicated cases 1

Addressing Anxiety Without Dismissing Cardiac Concerns

• While anxiety is common in patients with chest pain (42% prevalence in one study), it should be a diagnosis of exclusion after cardiac causes have been ruled out 4
• Only 8% of ED chest pain patients self-identify stress or anxiety as the cause of their symptoms, yet many have inadequate cardiac workups 5
• For patients with recurrent chest pain presentations who have already had negative cardiac workups, referral to a cognitive-behavioral therapist is reasonable (Class 2a recommendation) 1

Common Pitfalls to Avoid

• Premature attribution of chest pain to anxiety may lead to missed diagnoses of serious conditions, especially in younger patients who don't fit the typical cardiac profile 1
• Women and diverse patient populations are at particular risk for underdiagnosis when presenting with chest pain 1
• Anxiety and cardiac disease can coexist—patients with negative cardiac tests may have higher anxiety scores, but this doesn't exclude underlying cardiac pathology 4

When to Consider Anxiety as a Diagnosis

• Anxiety should only be considered as a cause of chest pain after:

  1. Appropriate cardiac testing has been completed and is negative 1
  2. Other potential causes (pulmonary, musculoskeletal, gastrointestinal) have been considered 1
  3. The patient has had recurrent, similar presentations with prior negative workups 1

• Even in patients with known anxiety disorders, chest pain warrants appropriate cardiac evaluation as these conditions can coexist 6

Follow-up Recommendations

• If cardiac causes are ruled out after appropriate testing, the clinician should discuss the findings with the patient and explain the relationship between anxiety and physical symptoms 1
• For patients with recurrent chest pain and negative cardiac workups, referral for cognitive-behavioral therapy has shown a 32% reduction in chest pain frequency 1
• Patients should be educated about when to seek emergency care for chest pain that differs from their typical pattern 1