Clinician Response to Exercise-Induced Chest Pain in a Young Adult
Exercise-induced chest pain in a young adult should never be dismissed as "probably anxiety" without appropriate cardiac evaluation first, as this may represent myocardial ischemia even in patients without traditional risk factors. 1
Initial Approach to Chest Pain Evaluation
- A focused cardiovascular examination must be performed initially to rule out serious causes such as acute coronary syndrome, aortic dissection, or pulmonary embolism 1
- Physical examination should specifically assess for tachycardia, abnormal heart sounds, or murmurs, though the exam may be normal in uncomplicated cardiac cases 1
- Basic diagnostic testing should include an electrocardiogram and chest radiograph for all patients with exercise-induced chest pain 2
Required Diagnostic Workup
- Patients with exercise-induced chest pain, especially with exertional pattern, ECG abnormalities, or cardiac risk factors should undergo further evaluation with troponin level measurement and cardiac stress testing 2, 3
- Consider coronary computed tomography angiography for further risk stratification in appropriate cases 3
- Clinical prediction rules can help determine the risk of pulmonary embolism, with D-dimer assay guiding the need for additional imaging such as helical CT or venous ultrasound 2
Addressing Potential Bias in Diagnosis
- Cultural competency is essential as biases may lead to premature dismissal of symptoms as anxiety, particularly in diverse patient populations 1
- Young adults who don't fit the typical cardiac profile are at particular risk for misdiagnosis when presenting with chest pain 1
- Women are especially vulnerable to having their chest pain symptoms attributed to anxiety rather than receiving appropriate cardiac evaluation 1, 4
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
- Even among patients who self-identify stress or anxiety as the cause of their chest pain, studies show they often have inadequate cardiac evaluation and no formal anxiety assessment 5
- Up to 42% of patients referred for stress testing may have anxiety symptoms, highlighting the importance of not dismissing cardiac causes prematurely 4
Follow-up Recommendations
- After ruling out cardiac causes through appropriate testing, discuss 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
- Educate patients about when to seek emergency care for chest pain that differs from their typical pattern 1
Common Pitfalls to Avoid
- Premature attribution of chest pain to anxiety without proper cardiac evaluation is a dangerous clinical error 1
- Patients with anxiety disorders often have chest pain that prompts medical evaluation, with studies showing 48% of patients with generalized anxiety disorder report chest pain 6
- Patients with negative cardiac evaluations and self-reported anxiety still have similar healthcare utilization and ED recidivism rates (approximately 25%) as those without reported anxiety, indicating ongoing medical concerns 5