What are the non-cardiac causes of chest pain and their management?

Non-Cardiac Causes of Chest Pain and Management

The differential diagnosis for non-cardiac causes of chest pain is broad and includes respiratory, musculoskeletal, gastrointestinal, psychological, and other causes, with musculoskeletal causes being the most common. 1

Major Categories of Non-Cardiac Chest Pain

1. Musculoskeletal Causes

• Costochondritis - characterized by pain reproducible with palpation of the costochondral junctions 1, 2
• Muscle strain - often related to physical activity or overexertion 2
• Rib fracture - may be related to trauma or occult injury 1, 2
• Cervical radiculopathy - pain radiating from cervical spine 1

2. Gastrointestinal Causes

• Gastroesophageal reflux disease (GERD) - most common esophageal cause of non-cardiac chest pain 1, 3
• Esophageal spasm and dysmotility - can mimic cardiac pain 1, 3
• Peptic ulcer disease - may present with epigastric pain radiating to chest 1
• Pancreatitis - typically presents with epigastric pain radiating to back 1
• Biliary disease - right upper quadrant pain that may radiate 1

3. Respiratory Causes

• Pulmonary embolism (PE) - characterized by tachycardia, dyspnea, and pain with inspiration in >90% of patients 1
• Pneumonia - may cause localized pleuritic chest pain with friction rub 1
• Pneumothorax - pleuritic chest pain with unilateral decreased or absent breath sounds 1
• Pleuritis - sharp pain that worsens with deep breathing 1

4. Psychological Causes

• Anxiety disorders and panic attacks - often associated with other somatic symptoms 1
• Depression - frequently comorbid with non-cardiac chest pain 4
• Somatoform disorders - physical symptoms without identifiable organic cause 1

5. Other Causes

• Herpes zoster - painful rash in a dermatomal distribution 1
• Sickle cell crisis - may present with acute chest syndrome 1
• Aortic dissection - sudden onset of severe chest or back pain with pulse differential (30% of patients) 1

Diagnostic Approach

1. Initial Assessment:

   • Evaluate for life-threatening causes (aortic dissection, PE, esophageal rupture) 1
   • Focused cardiovascular examination to identify complications 1

2. When to Suspect Non-Cardiac Causes:

   • Persistent or recurring symptoms despite negative cardiac evaluation 1
   • Pain reproducible with palpation or specific movements 2
   • Pleuritic quality or positional nature of pain 1

3. Gastrointestinal Evaluation:

   • For recurrent chest pain without evidence of cardiac or pulmonary cause, evaluation for gastrointestinal causes is reasonable (Class 2a recommendation) 1
   • Consider upper endoscopy when esophageal cause is suspected 1
   • Trial of empiric acid suppression therapy for suspected GERD 1
   • Consider esophageal function testing and pH monitoring if symptoms persist despite treatment 1

4. Psychological Assessment:

   • For patients with recurrent, similar presentations with no evidence of physiological cause, referral to a cognitive-behavioral therapist is reasonable (Class 2a recommendation) 1
   • Cognitive-behavioral therapy has shown a 32% reduction in chest pain frequency 1

Management Strategies

Musculoskeletal Pain

• Manual therapy for musculoskeletal causes 2
• Topical or oral analgesics and anti-inflammatory agents 2
• Focal injection of local anesthetic for diagnostic and therapeutic purposes 2

GERD-Related Chest Pain

• Proton pump inhibitors are the mainstay of treatment 3, 4
• Lifestyle modifications (avoiding trigger foods, elevating head of bed) 3

Esophageal Dysmotility

• Medical interventions targeting smooth muscle relaxation 3
• Consider endoscopic or surgical interventions for severe cases 3

Functional Chest Pain

• Neuromodulators for pain management 3
• Address psychological comorbidities in all patients with non-cardiac chest pain 3, 4

Special Considerations

• Sickle Cell Disease: Patients with sickle cell disease reporting acute chest pain require emergency transfer to acute care settings to exclude acute chest syndrome 1

• Valvular Heart Disease: Although cardiac in origin, valvular heart disease can present with chest pain that may be confused with non-cardiac causes, particularly in stenotic valvular disease 1

• Recurrent Presentations: For patients with multiple similar presentations and negative cardiac workups, psychological factors should be addressed, as these are often overlooked in clinical practice 1, 4

Pitfalls to Avoid

• Assuming all non-cardiac chest pain is benign - some causes like PE and aortic dissection are life-threatening 1
• Failing to consider psychological factors - these are common but frequently overlooked 1, 4
• Incomplete evaluation after negative cardiac testing - a specific non-cardiac diagnosis should be pursued 3, 5
• Overlooking medication-related causes - NSAIDs, potassium supplements, iron, and bisphosphonates can cause esophageal irritation 1