Management of Chest Pain Due to Distress
For chest pain due to distress (non-cardiac chest pain), the priority is to first rule out life-threatening cardiac and other serious causes through rapid ECG and clinical assessment, then provide reassurance, symptom management, and consider psychological intervention if symptoms persist. 1, 2
Initial Assessment: Rule Out Life-Threatening Causes
Even when distress is suspected, you must first exclude cardiac and other serious pathology:
- Obtain a 12-lead ECG within 10 minutes to identify ST-segment elevation myocardial infarction (STEMI) or other acute coronary syndromes 1, 3
- Place patient on cardiac monitor immediately with emergency resuscitation equipment nearby 2
- Draw cardiac biomarkers (troponin T or I, CK-MB) on admission and at 10-12 hours after symptom onset 1, 3
- Assess vital signs including blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature 2, 3
Key Clinical Features That Suggest Lower Risk (Non-Cardiac Pain)
- Pain that varies with respiration, body position, or food intake 4
- Pain that is well-localized on the chest wall with reproducible tenderness 4
- Absence of radiation to arm, jaw, neck, or back 4
- No associated symptoms such as cold sweats, nausea, vomiting, or syncope 4
Critical Pitfall to Avoid
- Do not rely solely on pain severity to determine urgency—severity is a poor predictor of imminent complications such as cardiac arrest 2
- Do not discharge patients with normal ECG without further evaluation—consider serial troponin measurements 6-12 hours apart 2
Management Once Cardiac Causes Are Excluded
Immediate Symptom Relief
- Provide reassurance after excluding serious pathology—many patients with non-cardiac chest pain experience persistent symptoms due to anxiety 5, 6
- Administer appropriate analgesia if pain is severe, though avoid opioids if cardiac etiology has been definitively excluded 7
- Address anxiety directly as stress and anxiety are common among patients with non-cardiac chest pain 5
Observation and Monitoring
- Observe low-to-moderate risk patients for 10-12 hours after symptom onset in a chest pain unit with resuscitation capabilities and cardiac monitoring 1, 3
- Perform stress testing or other non-invasive testing for patients with normal initial evaluations but intermediate risk 1
Addressing Persistent Symptoms
For patients with confirmed non-cardiac chest pain and distress:
- Recognize that 55.5% of patients with nonspecific chest pain show symptom persistence at 6 months, indicating standard medical care often does not offer sufficient symptom relief 6
- Avoid overinvestigation—repeated cardiac testing provides no clinical benefit once cardiac causes are excluded and may reinforce patient anxiety 6
- Consider psychological referral for patients with persistent symptoms and anxiety, as cognitive-behavioral interventions have been found effective for this group 5
- Provide self-help interventions addressing stress and anxiety, which are acceptable and relevant to patients with non-cardiac chest pain 5
Common Pitfalls in Non-Cardiac Chest Pain Management
- Most patients with persistent nonspecific chest pain are referred to cardiologists (often repeatedly), while less than 2% receive mental health referrals despite the psychological component 6
- Approximately 10.7% of patients undergo inappropriate health care usage, defined as 2 or more cardiologist visits or 3 or more cardiac diagnostic investigations after exclusion of cardiac disease 6
- Repeated cardiac testing reinforces patient belief that something serious is being missed, perpetuating anxiety and symptom persistence 5, 6
Differential Diagnosis to Consider
While managing distress-related chest pain, remain vigilant for: