What can be administered in the emergency department (ED) to help alleviate chest pain of non-cardiac origin?

From the Guidelines

For non-cardiac chest pain in the emergency department, NSAIDs like ibuprofen (400-800mg) or ketorolac (15-30mg IV) are first-line treatments. According to the most recent guidelines, after ruling out cardiac causes through appropriate testing (ECG, troponin, etc.), treatment should be tailored to the suspected cause of non-cardiac chest pain 1.

Treatment Options

• For suspected musculoskeletal pain, muscle relaxants such as cyclobenzaprine (5-10mg) or methocarbamol (750-1000mg) may help.
• If GERD is suspected, proton pump inhibitors like pantoprazole (40mg IV) or omeprazole (40mg oral) can provide relief.
• For anxiety-related chest pain, short-acting benzodiazepines like lorazepam (0.5-1mg) may be appropriate.
• Acetaminophen (1000mg) can be used for patients with contraindications to NSAIDs. Pain management should address both symptoms and underlying causes, with follow-up care arranged based on the specific diagnosis. Patients should be educated about their condition and when to return if symptoms worsen or change in character. The 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain emphasizes the importance of thorough clinical evaluation to distinguish between serious and benign causes of chest pain 1. Although an older study suggested the use of nitrates, β-blockers, and calcium antagonists for patients with noncardiac chest pain, this recommendation is based on a lower level of evidence (Level of Evidence: C) and is not supported by more recent guidelines 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Administration of Medications for Non-Cardiac Chest Pain in the ED

In the emergency department (ED), several medications can be administered to help alleviate chest pain of non-cardiac origin, including:

• Analgesics, which were prescribed in 51% of cases 2
• Proton pump inhibitors (PPIs), which can be used to diagnose and treat gastroesophageal reflux disease (GERD), a common cause of non-cardiac chest pain 2, 3, 4
• Anti-spasmodics, pain modulators, and smooth muscle relaxants, which can be used to treat esophageal motor disorders 3
• Anti-depressants, such as trazadone, tricyclic anti-depressants, selective serotonin reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors, which can be used to treat functional chest pain 3, 4

Treatment Approaches

The treatment approach for non-cardiac chest pain in the ED may involve:

• A trial of PPI therapy to diagnose and treat GERD 2, 3, 4
• The use of muscle relaxants, such as calcium channel blockers and nitrates, to treat esophageal dysmotility 3, 4
• The use of pain modulators, such as pregabalin and ramelteon, to treat functional chest pain 3, 4
• Cognitive behavioral therapy and other psychological techniques, such as hypnotherapy and group therapy, to address underlying psychiatric comorbidities 4