What are the non-cardiac causes of sharp chest pain?

Non-Cardiac Causes of Sharp Chest Pain

Musculoskeletal causes are the most common non-cardiac source of sharp chest pain, with costochondritis leading the list, followed by gastrointestinal disorders (particularly GERD), pulmonary conditions, and psychological factors. 1, 2

Life-Threatening Non-Cardiac Causes (Exclude First)

Before attributing sharp chest pain to benign causes, you must rule out these potentially fatal conditions:

• Pulmonary embolism: Presents with tachycardia and dyspnea in >90% of patients, accompanied by sharp pleuritic pain that worsens with inspiration 1, 2, 3
• Aortic dissection: Sudden onset of severe "ripping" or "tearing" chest or back pain with pulse differential in 30% of cases 1, 2, 3
• Pneumothorax: Classic triad of dyspnea, sharp pleuritic pain on inspiration, and unilateral absent breath sounds with hyperresonant percussion 2, 3
• Esophageal rupture: Requires immediate consideration in the initial assessment 2

Common Musculoskeletal Causes

Costochondritis is the single most frequent non-cardiac cause of sharp chest pain, characterized by:

• Pain reproducible with palpation of the costochondral junctions 1, 2
• Sharp, localized discomfort that may mimic cardiac pain 2

Critical pitfall: 7% of patients with reproducible chest wall tenderness on palpation still have acute coronary syndrome, so reproducible pain does NOT exclude cardiac disease 3

Other musculoskeletal causes include:

• Cervical radiculopathy: Pain radiating from the cervical spine 1, 2
• Muscle strain: Often related to recent activity or trauma 1
• Rib fracture: May result from recent or occult chest trauma 1

Gastrointestinal Causes

Gastroesophageal reflux disease (GERD) is the most common esophageal cause of non-cardiac chest pain 1, 2:

• Presents as squeezing or burning retrosternal pain 1
• Duration of minutes to hours, often occurs after meals or at night 1
• May worsen with stress and can mimic myocardial ischemia 1
• May or may not resolve with antacids depending on severity 1

Other gastrointestinal causes:

• Esophageal motility disorders (achalasia, distal esophageal spasm, nutcracker esophagus): Present as squeezing retrosternal pain or spasm, often with dysphagia 1
• Esophagitis: Caused by medications (NSAIDs, potassium supplements, iron, bisphosphonates), infections (candidiasis), or radiation injury 1, 2
• Eosinophilic esophagitis: Associated with allergic conditions, diagnosed by biopsy 1
• Peptic ulcer disease: Epigastric pain that may radiate to the chest 1, 2
• Gastritis: From medications or peptic ulcer disease 1

Pulmonary Causes

• Pneumonia: Localized pleuritic pain with fever, productive cough, regional dullness to percussion, egophony, and possible friction rub 2, 3
• Pleuritis: Sharp pain that worsens with deep breathing 2
• Pleural effusion: May cause ongoing pleuritic discomfort 3

Psychological Causes

Psychological factors are common but frequently overlooked in clinical practice 1, 2:

• Panic disorder and anxiety: Often associated with other somatic symptoms including chest pain 1, 2
• Depression: Highly prevalent in patients with non-cardiac chest pain 1
• Somatoform disorders: Physical symptoms without identifiable organic cause 1, 2

Key evidence: In low-risk chest pain patients without cardiac disease, depression, anxiety, and gastroesophageal syndromes each exceeded coronary artery disease by almost 10-fold 1

Other Causes

• Herpes zoster: Painful rash in a dermatomal distribution, pain triggered by touch 1, 2, 4
• Sickle cell crisis: May present with acute chest syndrome 1, 2
• Pericarditis: Sharp pleuritic pain that improves sitting forward and worsens supine 3

Diagnostic Algorithm

Step 1: Immediate assessment for life-threatening causes

• Obtain ECG within 10 minutes of presentation 1, 3
• Perform chest radiography to evaluate for pneumothorax, pneumonia, pleural effusion, or widened mediastinum 2, 3
• Measure cardiac troponin as soon as possible 3
• Consider CT chest with contrast if pulmonary embolism or aortic dissection suspected 1

Step 2: Evaluate for non-cardiac causes if cardiac workup is negative

• Patients with persistent or recurring symptoms despite negative stress test or anatomic cardiac evaluation should be evaluated for non-cardiac causes 1
• Perform focused physical examination looking for chest wall tenderness, friction rub, unilateral decreased breath sounds, or dermatomal rash 2, 3, 4

Step 3: Targeted evaluation based on clinical presentation

For suspected gastrointestinal causes in patients with recurrent chest pain without cardiac or pulmonary cause:

• Trial of empiric high-dose proton pump inhibitor therapy for suspected GERD 1, 3
• Consider upper endoscopy when esophageal cause is suspected 2
• Esophageal function testing and pH monitoring if symptoms persist despite treatment 2

For suspected musculoskeletal causes:

• Treat as costochondritis with anti-inflammatory medications if cardiac testing is negative and pain is reproducible with palpation 3

For suspected psychological causes:

• Referral to cognitive-behavioral therapist is reasonable for patients with recurrent similar presentations and negative workup for myocardial ischemia 1
• Cognitive-behavioral therapy has shown a 32% reduction in chest pain frequency over 3 months 1

Critical Pitfalls to Avoid

• Never assume all non-cardiac chest pain is benign: Pulmonary embolism, aortic dissection, and pneumothorax are life-threatening non-cardiac causes 2, 3
• Do not rely on reproducible chest wall tenderness alone: 7% of patients with palpable tenderness have acute coronary syndrome 3
• Do not use nitroglycerin response as a diagnostic criterion: Relief with nitroglycerin does not confirm or exclude myocardial ischemia 3
• Do not overlook psychological factors: These are common but clinicians have a low rate (<10%) of inquiry, documentation, or referral for psychological factors 1, 2
• Do not ignore medication-related causes: NSAIDs, potassium supplements, iron, and bisphosphonates can cause esophageal irritation 2
• Sharp, pleuritic pain does not exclude cardiac ischemia: While it makes ischemic heart disease less likely, it does not completely rule it out 3

Special Populations

• Women: More frequently present with atypical symptoms including back, neck, and jaw pain; use different word descriptors ("tearing," "terrifying") 1
• Older patients (≥75 years): Increased frequency of atypical presentations 1
• Patients with diabetes, renal insufficiency, or dementia: Higher likelihood of atypical presentations 1