What is the best course of action for a patient with recurrent chest pain, palpitations, and nausea, who has a history of anxiety and previous episodes of similar symptoms attributed to anxiety, now worsening over the past month?

Immediate Cardiac Evaluation Required Before Attributing to Anxiety

This patient requires urgent cardiac workup including ECG, troponin, and risk stratification before any consideration of anxiety as the primary diagnosis, given the worsening pattern, new nausea, and palpitations suggesting possible acute coronary syndrome or arrhythmia. 1, 2

Critical First Steps

• Obtain a 12-lead ECG within 10 minutes to assess for ST-segment changes, T-wave inversions, or arrhythmias that could indicate acute coronary syndrome or electrical abnormalities 1, 3
• Draw cardiac troponin immediately as 1-6% of ACS patients present with normal initial ECGs, and biomarkers are essential for ruling out myocardial injury 1, 3
• Assess vital signs including blood pressure, heart rate, respiratory rate, and oxygen saturation to identify hemodynamic instability 2
• Evaluate for high-risk features including diaphoresis, pallor, cool skin, radiation to arms/neck/jaw, and symptoms interrupting normal activity, which increase ACS likelihood 1, 3

Why Cardiac Evaluation Takes Priority

The worsening pattern over one month with new-onset nausea and palpitations ("skipped beats") represents a change from baseline that mandates cardiac investigation. 1 While previous episodes were attributed to anxiety, premature attribution to anxiety without appropriate cardiac testing is a critical pitfall that can lead to missed diagnoses of serious conditions. 2

• Palpitations associated with chest pain require electrocardiographic monitoring and echocardiography as first evaluation steps per European Heart Journal guidelines 1
• NSTE-ACS commonly presents with chest pain at rest or minimal exertion, often accompanied by nausea and diaphoresis - matching this patient's presentation 1
• Anxiety-related chest pain should only be diagnosed after cardiac workup is negative, not before 2

Risk Stratification Based on Initial Testing

If ECG Shows ST-Elevation or New LBBB:

• Activate STEMI protocol immediately with aspirin 250-500mg (chewable), establish IV access, and prepare for emergent catheterization 3

If ECG Shows ST-Depression, T-Wave Changes, or Elevated Troponin:

• Treat as NSTE-ACS with aspirin, antiplatelet therapy, anticoagulation, and cardiology consultation for risk stratification and potential catheterization 1, 3
• Admit for serial troponins and continuous monitoring as these patients require inpatient management 1

If Initial ECG and Troponin Are Normal But Symptoms Persist:

• Repeat ECG at 15-30 minute intervals during the first hour, especially if symptoms recur, as initial ECG can be nondiagnostic 1
• Consider posterior leads (V7-V9) and right-sided leads (V3R-V4R) as left circumflex or right coronary occlusions can be electrically silent 1
• Arrange prolonged electrocardiographic monitoring (loop monitoring) for patients with recurrent palpitations suggestive of arrhythmic events 1
• Perform echocardiography to assess for structural heart disease and regional wall motion abnormalities 1

Additional Cardiac Testing for Intermediate-Risk Patients

If acute coronary syndrome is ruled out but symptoms persist:

• Stress testing with echocardiography is recommended for patients with chest pain suggestive of ischemia, per European Heart Journal guidelines 1
• Consider coronary CT angiography in low-risk patients, which can provide more rapid and cost-effective diagnosis than stress perfusion imaging 1
• Holter monitoring or event recorder for 24-48 hours minimum to capture palpitation episodes and correlate with symptoms 1

Only After Negative Cardiac Workup: Consider Anxiety

If comprehensive cardiac evaluation is negative (normal ECG, negative troponins, normal echocardiogram, negative stress test or coronary imaging, and no arrhythmias on monitoring), then anxiety-related chest pain becomes the likely diagnosis. 1, 2

Distinguishing Features Supporting Anxiety Diagnosis:

• Chest tightness or pressure lasting minutes to hours (rather than seconds or constant for days) 2
• Symptoms that worsen with stress and improve with relaxation 2
• Accompanied by other anxiety symptoms including shortness of breath without hypoxia, sense of impending doom, trembling, or hyperventilation 2, 4
• Multiple somatic complaints beyond chest pain, such as dizziness, paresthesias, or gastrointestinal symptoms 1, 4

Management of Confirmed Anxiety-Related Chest Pain:

Referral to cognitive-behavioral therapy is the strongest evidence-based recommendation (Class 2a) for patients with recurrent chest pain and negative cardiac workups. 1, 2 Cognitive-behavioral therapy has demonstrated a 32% reduction in chest pain frequency over 3 months in this population. 1, 2

Pharmacotherapy Options:

• First-line: SSRIs (sertraline) or SNRIs (venlafaxine extended-release) for generalized anxiety disorder and panic disorder, with small to medium effect sizes compared to placebo 5, 6
• Benzodiazepines (alprazolam 0.25-0.5mg three times daily) may be used short-term for acute anxiety symptoms, but are not recommended for routine long-term use due to dependence risk 4, 6
• Continue medications for 6-12 months after remission before considering discontinuation 6

Immediate Anxiety Management:

• Provide reassurance about negative cardiac findings once testing is complete 2
• Teach sensory grounding techniques including environmental awareness exercises, breathing techniques, and progressive muscle relaxation 2

Common Pitfalls to Avoid

• Never attribute chest pain to anxiety in a patient with new or worsening symptoms without completing cardiac evaluation first - this is the most dangerous error 2, 3
• Do not rely on pain severity to determine urgency as severity poorly predicts cardiac complications 3
• Do not assume young age or previous anxiety diagnosis excludes cardiac disease - anxiety and cardiac disease frequently coexist 1, 7, 8
• Recognize that 42% of chest pain patients have anxiety symptoms, but this does not exclude concurrent cardiac pathology 7, 8
• Avoid extensive repetitive cardiac testing once comprehensive negative workup is complete - this reinforces illness behavior and delays appropriate mental health treatment 1, 2

Follow-Up Strategy

• If cardiac workup is negative, document this clearly and explain findings to patient to reduce health anxiety 1, 2
• Refer to cognitive-behavioral therapist rather than continuing cardiac testing 1, 2
• Consider psychiatric assessment for patients with frequent recurrent symptoms and multiple somatic complaints 1
• Reassess periodically as anxiety disorders are chronic and may require ongoing treatment 4, 5