How to approach a patient complaining of symptoms of anxiety and chest pain?

Approach to a Patient with Anxiety and Chest Pain

When evaluating a patient with both anxiety and chest pain, it is essential to first rule out life-threatening cardiac conditions before attributing symptoms to anxiety, as premature attribution to anxiety can lead to missed diagnoses of serious conditions. 1

Initial Evaluation

• Always begin with cardiac evaluation to rule out acute coronary syndrome (ACS), as chest pain with anxiety symptoms could still represent a cardiac emergency 2
• Obtain a 12-lead ECG immediately, as its sensitivity to identify ischemia may be as low as 50%, and 2-4% of patients with evolving myocardial infarction may have normal ECG findings 2
• Assess vital signs, with particular attention to blood pressure, heart rate, respiratory rate, and oxygen saturation 2
• Evaluate for associated symptoms that suggest cardiac etiology: diaphoresis, pallor, cool skin, nausea, vomiting, and dyspnea 2
• Consider cardiac biomarkers (troponin) to help rule out myocardial infarction 2

Distinguishing Features

• Anxiety-related chest pain often presents as:
  • Squeezing or tightness in the chest that may last minutes to hours 1
  • Pain that worsens with stress 1
  • Accompanied by other anxiety symptoms: shortness of breath, palpitations, sweating, trembling, fear of losing control 3, 4
• Cardiac chest pain typically presents as:
  • Diffuse pain over the anterior chest wall rather than localized 2
  • May radiate to arms, neck, and back 2
  • Often accompanied by autonomic symptoms (diaphoresis, pallor) 2

Management Algorithm

1. For all patients with chest pain and anxiety symptoms:

   • Administer oxygen if dyspnea, hypoxemia, or signs of heart failure are present 2
   • Consider ECG, cardiac biomarkers, and appropriate cardiac workup first 2

2. If acute cardiac conditions are ruled out:

   • Provide reassurance about negative cardiac findings 2
   • Consider non-invasive cardiac testing (stress testing, echocardiography) for patients with intermediate risk 2

3. For confirmed anxiety-related chest pain:

   • Referral to cognitive-behavioral therapy is strongly recommended for patients with recurrent presentations and negative cardiac workups (Class 2a recommendation) 2
   • Consider pharmacologic treatment:
     • For acute anxiety: benzodiazepines like alprazolam may be considered for short-term management 3
     • For chronic anxiety disorder: SSRIs like sertraline are appropriate for long-term management 4
   • Teach sensory grounding techniques and breathing exercises for acute symptom management 1

Common Pitfalls to Avoid

• Premature attribution of chest pain to anxiety before adequate cardiac evaluation 1, 5
• Failure to recognize that anxiety and cardiac conditions can coexist - patients with known anxiety disorders still require appropriate cardiac evaluation 1, 6
• Overinvestigation of low-risk patients with recurrent presentations, leading to unnecessary radiation exposure and healthcare costs 6
• Under-recognition and under-treatment of anxiety disorders in chest pain patients - studies show only about half of patients with severe anxiety are diagnosed and only about a quarter receive treatment 5
• Failure to refer patients with non-cardiac chest pain to mental health services 2

Follow-up Considerations

• For patients with recurrent, similar presentations and negative cardiac workups, cognitive-behavioral therapy has shown a 32% reduction in chest pain frequency 2
• Consider screening for generalized anxiety disorder, as 48% of patients with this condition report chest pain 7
• Monitor for comorbid conditions like depression, which often coexists with anxiety and may complicate management 8
• Educate patients about the physiological connection between anxiety and physical symptoms to improve understanding and treatment adherence 1

Special Considerations

• Women may describe chest pain differently than men, using terms like "tearing" more frequently and experiencing pain more often in the back, neck, and jaw 2
• Patients with anxiety and chest pain have similar ED recidivism rates (approximately 25%) compared to those without anxiety, indicating the importance of effective treatment 6
• Consider that chest pain in anxiety may be related to episodes of excessive worry rather than panic attacks in some patients 7