What is the treatment for atypical chest pain?

Treatment for Atypical Chest Pain

The treatment for atypical chest pain should focus on identifying and addressing the underlying cause, as cardiac, musculoskeletal, gastrointestinal, and psychological conditions can all present with atypical chest pain features. 1

Initial Assessment and Diagnosis

• Avoid using the term "atypical chest pain" as it can be misinterpreted as benign; instead, classify chest pain as cardiac, possibly cardiac, or noncardiac based on specific characteristics 1
• Evaluate for features suggesting lower likelihood of cardiac ischemia: sharp or stabbing quality, pleuritic nature (pain with breathing), reproducibility with movement or palpation, very brief duration (seconds), or pain that is maximal at onset 1
• Consider that atypical presentations of acute coronary syndrome are more common in older adults (>75 years), younger adults (25-40 years), women, and patients with diabetes 1
• Obtain a 12-lead ECG within 10 minutes of arrival for patients with suspected acute coronary syndrome, even with atypical presentations 1
• Measure cardiac troponin levels to rule out myocardial injury in patients with suspected cardiac etiology 1

Diagnostic Testing Based on Suspected Etiology

• For suspected cardiac causes with low probability of coronary artery disease:

  • Coronary CT angiography (CCTA) has excellent negative predictive value (approaching 100%) for excluding coronary artery disease 1
  • Stress echocardiography or myocardial perfusion imaging may be appropriate alternatives 1
  • Resting transthoracic echocardiography can identify non-ischemic cardiac causes such as pericarditis or valvular disease 1

• For suspected non-cardiac causes:

  • Consider chest CT with IV contrast if pulmonary embolism or aortic dissection is suspected 1
  • Evaluate for gastrointestinal causes (esophageal spasm, gastroesophageal reflux disease) with appropriate testing 1, 2
  • Assess for musculoskeletal pain through physical examination and response to analgesics 3

Treatment Approaches by Etiology

Cardiac Causes

• For confirmed or suspected coronary artery disease:
  • Antiplatelet therapy (aspirin) 4
  • Consider adding P2Y12 inhibitor if acute coronary syndrome is confirmed 4
  • Initiate statin therapy and beta-blockers as appropriate 4
  • Nitroglycerin for symptomatic relief of anginal pain 1

Musculoskeletal Causes (Most Common Non-Cardiac Cause)

• NSAIDs or acetaminophen for pain relief 3
• Physical therapy for persistent chest wall pain 2
• Heat or ice application to affected areas 2

Gastrointestinal Causes

• Proton pump inhibitors for suspected GERD or esophageal disorders 2
• Antispasmodics for esophageal spasm 2, 5
• Dietary modifications to reduce reflux symptoms 2

Psychological Causes

• Cognitive behavioral therapy for anxiety-related chest pain 2
• Consider appropriate psychiatric medications for anxiety or depression 2
• Breathing exercises and relaxation techniques 2

Follow-up and Monitoring

• Patients with non-cardiac chest pain have significantly lower mortality (2.9%) compared to those with confirmed cardiac events (18.3%) at one year 3
• Despite lower mortality, symptoms often persist or recur, requiring ongoing management 3
• Consider structured follow-up for patients discharged without a definitive diagnosis 3, 6

Important Considerations

• Avoid excessive cardiac testing in patients with clearly non-cardiac pain features to prevent unnecessary procedures and patient anxiety 2, 5
• Be aware that some non-cardiac conditions (like esophageal spasm) may respond to nitroglycerin, potentially causing diagnostic confusion 5
• Consider a multidisciplinary approach for patients with persistent, unexplained chest pain 2