What is the best approach to manage non-cardiac chest tightness associated with anxiety in a patient undergoing perimenopause?

Management of Non-Cardiac Chest Tightness Associated with Anxiety in Perimenopause

For patients with recurrent non-cardiac chest tightness associated with anxiety during perimenopause, referral to cognitive-behavioral therapy is the most effective approach, showing a 32% reduction in chest pain frequency. 1, 2

Initial Evaluation to Rule Out Cardiac Causes

• Always begin with cardiac evaluation to rule out acute coronary syndrome before attributing chest pain to anxiety, 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% 1, 2
• Assess vital signs including 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 1, 2
• Consider cardiac biomarkers (troponin) to help rule out myocardial infarction 2

Understanding Anxiety-Related Chest Tightness in Perimenopause

• Anxiety triggers the sympathetic nervous system, causing increased heart rate, blood pressure elevation, and muscle tension in the chest wall, creating a sensation of tightness or pressure 2
• Specific mechanisms include central nervous system-visceral interactions, heightened body vigilance, lowered pain thresholds, and sympathetic activation 1, 2
• Hyperventilation can cause chest muscle spasms, contributing to the sensation of chest tightness 2
• Perimenopausal hormonal fluctuations can exacerbate anxiety symptoms, potentially worsening chest tightness 2

Management Approach After Cardiac Causes Are Ruled Out

1. First-line: Cognitive-Behavioral Therapy

   • Referral to a cognitive-behavioral therapist is strongly recommended (Class 2a recommendation) 1, 2
   • CBT has shown a 32% reduction in chest pain frequency in patients with non-cardiac chest pain 1, 2
   • Approaches using cognitive-behavioral methods were found to be most effective for these patients 1

2. Acute Symptom Management

   • Teach sensory grounding techniques, such as environmental awareness exercises, cognitive distractions, and breathing techniques 2
   • Progressive muscle relaxation can help manage acute anxiety symptoms 2
   • Provide reassurance about negative cardiac findings to reduce anxiety 2

3. Pharmacological Considerations

   • Evidence for antidepressants and anxiolytics in treating non-cardiac chest pain is mixed 1
   • Consider short-term anxiolytics for acute symptoms while initiating CBT 1
   • For perimenopausal patients, discuss whether hormone therapy might help with overall symptom management if other menopausal symptoms are present 2

Important Clinical Considerations

• Patients with non-cardiac chest pain often undergo extensive and repetitive cardiac testing with low referral rates to mental health services (less than 10%) 1, 2
• Cardiac anxiety is strongly associated with healthcare-seeking behavior in patients with non-cardiac chest pain 3, 4
• About 26% of patients with non-cardiac chest pain report moderate depressive symptoms, and 42% report moderate cardiac anxiety 3
• Type D personality (tendency to experience emotional distress) is independently associated with increased risk of panic disorder or depression in patients with non-cardiac chest pain 5

Pitfalls to Avoid

• Premature attribution of chest pain to anxiety before appropriate cardiac testing has been completed 2, 6
• Failing to recognize that 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 1, 2
• Underestimating the impact of psychological distress on healthcare utilization - patients with higher levels of cardiac anxiety seek healthcare more frequently 3, 4
• Neglecting to address both the physical sensations and the psychological components of chest pain 7

Follow-up Recommendations

• Educate patients about the relationship between anxiety and physical symptoms 2, 6
• Schedule regular follow-up appointments to monitor symptoms and response to therapy 2
• Instruct patients to seek emergency care for chest pain that differs from their typical pattern 2, 6
• Consider self-help interventions as adjuncts to professional care, which have shown acceptability and feasibility in emergency department settings 8