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

Proper Evaluation of Exercise-Induced Chest Pain in Young Adults

Exercise-induced chest pain in a young adult requires a thorough cardiac evaluation and should never be dismissed as "probably anxiety" without appropriate testing, as this may lead to missed diagnoses of serious conditions. 1

Initial Approach

• Exercise-induced chest pain warrants careful evaluation for potentially serious causes including acute coronary syndrome, aortic dissection, or pulmonary embolism, even in young patients without traditional risk factors 1
• A focused cardiovascular examination should be performed initially, looking specifically for tachycardia, abnormal heart sounds, or murmurs, though the exam may be normal in uncomplicated cases 1
• Diagnostic workup should include, at minimum, an electrocardiogram and chest radiograph for all patients presenting with chest pain 2

Required Diagnostic Testing

• Patients with exercise-induced chest pain, especially with any cardiac risk factors or ECG abnormalities, should undergo measurement of troponin levels and appropriate cardiac stress testing 1, 2
• For patients with suspected pulmonary embolism, a clinical prediction rule combined with D-dimer testing can help determine the need for further imaging studies 2
• Coronary computed tomography angiography or stress testing can be valuable tools for risk stratification in the emergency department setting 3

Avoiding Common Pitfalls

• Premature attribution of chest pain to anxiety is a significant clinical error that disproportionately affects younger patients who don't fit the typical cardiac profile 1
• Studies show that 8% of chest pain patients self-identify stress or anxiety as the cause of their symptoms, yet these patients still require appropriate cardiac evaluation 4
• Women and diverse patient populations are at particular risk for underdiagnosis when presenting with chest pain 1
• Clinician bias can lead to dismissal of symptoms as anxiety without proper evaluation; cultural competency training can help address these biases 1

When to Consider Anxiety as a Diagnosis

• Anxiety should only be considered as a cause of chest pain AFTER appropriate cardiac testing has been completed and is negative 1
• The prevalence of anxiety symptoms in chest pain patients referred for stress testing is approximately 42%, highlighting the importance of considering psychological factors after ruling out cardiac causes 5
• Patients with negative cardiac tests may actually have higher anxiety and depression scores than those with positive tests, suggesting a complex relationship between psychological factors and chest pain 5

Recommended Approach for the Clinician

• Acknowledge the patient's concerns and explain that while anxiety can cause chest pain, serious cardiac conditions must first be ruled out 1
• Order appropriate cardiac testing based on the patient's risk factors and presentation 1, 2
• If cardiac causes are ruled out after appropriate testing, 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, consider referral for cognitive-behavioral therapy, which has shown a 32% reduction in chest pain frequency 1
• Educate patients about when to seek emergency care for chest pain that differs from their typical pattern 1

Special Considerations

• Generalized anxiety disorder (GAD) may be a common diagnosis in chest pain patients with no demonstrable coronary disease, with studies showing 48% of GAD patients reporting a history of chest pain 6
• Pain reproducible by palpation is more likely to be musculoskeletal than ischemic, but this should not preclude appropriate cardiac evaluation 2
• New cardiac troponin assays, especially when used with clinical decision algorithms, can help clinicians rapidly exclude acute myocardial infarction 3