What is the best course of action to manage recurring chest pain and anxiety with a history of cardiac anxiety and normal cardiac tests?

Management of Recurrent Chest Pain with Cardiac Anxiety and Normal Cardiac Testing

With clean cardiac testing from one year ago (normal CTA, 11 METS on stress test, normal echo), your current chest pain is most likely anxiety-related and does not require repeat cardiac testing at this time—instead, you should be referred to cognitive-behavioral therapy, which has demonstrated a 32% reduction in chest pain frequency for patients in your exact situation. 1

Understanding Your Situation

Your comprehensive cardiac workup from one year ago provides strong reassurance:

• Normal coronary CT angiography excludes significant coronary artery disease 1
• 11 METS on exercise stress test indicates excellent functional capacity (normal is 7-10 METS for most adults) and makes cardiac ischemia highly unlikely 1
• Normal echocardiogram rules out structural heart disease 1

According to the 2021 AHA/ACC guidelines, patients with recurrent low-risk chest pain and previous normal testing within 2 years do not need further diagnostic testing beyond a single high-sensitivity troponin if symptoms are similar to prior presentations 1

Why This Is Likely Anxiety-Related

The close association between chest pain and psychological syndromes such as anxiety, panic attacks, and cardiophobia suggests a psychogenic origin in many patients like yourself 1

Specific mechanisms explaining your symptoms include:

• Central nervous system-visceral interactions that create real physical sensations 1, 2
• Sympathetic nervous system activation causing increased heart rate, blood pressure elevation, and chest wall muscle tension 2
• Heightened body vigilance and lowered pain thresholds that amplify normal sensations 1, 2
• Hyperventilation causing chest muscle spasms 2

Key distinguishing features of anxiety-related chest pain:

• Pain described as squeezing, tightness, or pressure 2
• Duration of minutes to hours (cardiac pain typically lasts >10 minutes if ischemic) 1
• Symptoms that worsen with stress or worry 2
• Accompanied by shortness of breath, palpitations, sweating, or sense of doom 2

The Recommended Treatment Approach

The 2021 AHA/ACC guidelines provide a Class 2a recommendation (reasonable to perform) for referral to cognitive-behavioral therapy for patients with recurrent chest pain and negative cardiac workups 1

This recommendation is based on a Cochrane systematic review of 17 randomized controlled trials showing that cognitive-behavioral therapy achieved a 32% reduction in chest pain frequency over 3 months 1

Why cognitive-behavioral therapy works:

• Identifies your specific fears about chest pain and cardiac disease 3
• Educates you about how anxiety produces real physical sensations including chest pain 3, 4
• Breaks the vicious cycle where anxiety increases symptoms, which increases worry, which increases symptoms 3
• Reduces heart-focused anxiety, which directly mediates chest pain reduction 4

Research specifically comparing treatments found that CBT was significantly superior to both placebo and the antidepressant paroxetine in reducing non-cardiac chest pain 4

When You Should Seek Emergency Evaluation

Despite your anxiety diagnosis, you should still seek immediate medical evaluation if you experience: 1

• Chest pain that interrupts normal activity and differs from your typical pattern 1
• Pain accompanied by cold sweats, nausea, vomiting, or fainting 1
• New-onset shortness of breath at rest 1
• Pain lasting >10 minutes at rest that feels like pressure or squeezing 1

Immediate Self-Management Strategies

While awaiting cognitive-behavioral therapy referral, you can use these evidence-based techniques 2:

• Sensory grounding: Focus on environmental awareness (name 5 things you see, 4 you can touch, 3 you hear, 2 you smell, 1 you taste) 2
• Breathing techniques: Slow, controlled breathing (inhale for 4 counts, hold for 4, exhale for 6) 2
• Progressive muscle relaxation: Systematically tense and release muscle groups 2

Critical Pitfalls to Avoid

The most important caveat: Anxiety should only be considered as the cause of chest pain after appropriate cardiac testing has been completed and is negative 2, 5

However, patients like you with documented negative cardiac workups often undergo extensive and repetitive cardiac testing with low referral rates to mental health services—this represents a lost opportunity for effective treatment 1

Depression and anxiety screening is specifically recommended by the 2022 SAEM guidelines for patients with recurrent low-risk chest pain, as this affects healthcare utilization and return visits 1

Follow-Up Plan

Schedule an appointment with your primary care physician to:

• Discuss your anxiety symptoms and obtain a formal referral to a cognitive-behavioral therapist 1
• Consider screening for depression, which is present in 31% of patients with chest pain and often coexists with anxiety 6
• Review when you should seek emergency care versus managing symptoms at home 1

The prognosis for patients with non-cardiac chest pain is largely devoid of cardiac complications, but symptoms often persist without appropriate psychological treatment 1, 7