What are the non-cardiac causes of a heavy chest feeling?

Non-Cardiac Causes of Chest Heaviness

The most common non-cardiac causes of chest heaviness include musculoskeletal conditions, gastrointestinal disorders (particularly GERD), pulmonary conditions, anxiety/psychiatric disorders, and neurological issues. 1

Gastrointestinal Causes

• Gastroesophageal reflux disease (GERD) is the most common esophageal cause of non-cardiac chest pain, often presenting as pressure or burning sensation 1, 2
• Peptic ulcer disease may present with epigastric pain radiating to the chest 1
• Esophageal motility disorders including esophageal spasm can cause chest heaviness or tightness 2
• Gastritis and other upper GI inflammatory conditions can mimic cardiac chest pain 3

Musculoskeletal Causes

• Costochondritis (inflammation of the cartilage connecting ribs to sternum) is the most common musculoskeletal cause, characterized by pain reproducible with palpation 1
• Cervical radiculopathy can cause pain radiating from the cervical spine to the chest 1
• Muscle strain or inflammation in chest wall muscles can create a sensation of heaviness 1
• Fibromyalgia can present with diffuse chest wall pain and heaviness 4

Pulmonary Causes

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

Psychological/Psychiatric Causes

• Anxiety disorders and panic attacks frequently present with chest tightness or heaviness and are often associated with other somatic symptoms 1, 5
• During anxiety, the sympathetic nervous system activation causes increased heart rate, blood pressure elevation, and muscle tension in the chest wall, creating a sensation of tightness or pressure 5
• Hyperventilation associated with anxiety can cause chest muscle spasms, contributing to the sensation of chest heaviness 5
• Somatoform disorders present with physical symptoms without identifiable organic cause 1

Other Causes

• Herpes zoster (shingles) affecting thoracic dermatomes can cause burning chest pain 1
• Sickle cell crisis may present with acute chest syndrome 1
• Aortic dissection presents with sudden onset of severe chest or back pain with pulse differential in 30% of patients 1
• Medication-related causes - NSAIDs, potassium supplements, iron, and bisphosphonates can cause esophageal irritation leading to chest discomfort 1
• Hormonal fluctuations during perimenopause can exacerbate anxiety symptoms, potentially worsening chest tightness 5

Diagnostic Approach

• Always begin by evaluating for life-threatening causes (aortic dissection, pulmonary embolism, esophageal rupture) 1
• For suspected GERD, a trial of empiric acid suppression therapy is recommended 1, 6
• Consider upper endoscopy when an esophageal cause is suspected 1
• For persistent symptoms despite treatment, consider esophageal function testing and pH monitoring 1
• In patients with multiple similar presentations and negative cardiac workups, psychological factors should be addressed 1, 2

Common Pitfalls to Avoid

• Assuming all non-cardiac chest pain is benign - some causes like pulmonary embolism and aortic dissection are life-threatening 1
• Failing to consider psychological factors - these are common but frequently overlooked 1, 5
• Premature attribution of chest pain to anxiety before appropriate cardiac testing has been completed 5
• Overlooking 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 5, 4

Management Considerations

• Cognitive-behavioral therapy has shown a 32% reduction in chest pain frequency in patients with non-cardiac chest pain 1, 5
• Address psychological comorbidities in all patients with non-cardiac chest pain 1
• For GERD-related chest pain, proton pump inhibitors are the treatment of choice 2, 6
• Neuromodulators may be prescribed for functional chest pain 2