How do you diagnose and manage non-cardiac chest pain?

Diagnosis and Management of Non-Cardiac Chest Pain

After excluding cardiac causes through appropriate testing (ECG, troponin, stress testing or anatomic evaluation), patients with persistent or recurrent chest pain should be systematically evaluated for gastrointestinal, musculoskeletal, pulmonary, and psychological etiologies, with gastrointestinal causes—particularly GERD—being the most common and warranting initial therapeutic trial. 1

Initial Diagnostic Approach

Confirm Cardiac Exclusion

• Patients must have documented negative cardiac workup including ECG (obtained within 10 minutes), cardiac troponin measurement, and either negative stress testing or anatomic cardiac evaluation before labeling chest pain as non-cardiac 1
• Avoid premature attribution to non-cardiac causes, as this represents a critical diagnostic pitfall 2

Systematic Differential Diagnosis

Gastrointestinal Causes (Most Common):

• GERD is the most prevalent esophageal cause, presenting as retrosternal pressure or burning that may last minutes to hours, often occurring after meals or at night 2, 3
• Peptic ulcer disease manifests with epigastric tenderness and pain that may radiate to chest 1, 2
• Esophageal motility disorders (achalasia, diffuse esophageal spasm, nutcracker esophagus) cause squeezing retrosternal pain often accompanied by dysphagia 1
• Medication-induced esophagitis from NSAIDs, potassium supplements, iron, or bisphosphonates 2

Musculoskeletal Causes (Most Common Non-Cardiac Overall):

• Costochondritis presents with tenderness of costochondral joints reproducible on palpation 1, 2, 4
• Muscle strain produces pain reproducible with movement or palpation 2, 4
• Cervical radiculopathy causes pain radiating from cervical spine to chest 2

Pulmonary Causes:

• Pulmonary embolism presents with tachycardia, dyspnea, and pleuritic pain in >90% of patients 1, 2
• Pneumonia shows fever, localized pleuritic pain, friction rub, regional dullness to percussion, and egophony 1, 4
• Pneumothorax manifests as dyspnea with pain worsening on inspiration and unilateral absent breath sounds 1, 4

Psychological/Psychiatric Causes:

• Anxiety disorders and panic attacks frequently cause chest tightness through sympathetic activation, increased heart rate, blood pressure elevation, and chest wall muscle tension 1, 2
• These are diagnoses of exclusion but are commonly overlooked despite high prevalence 1, 2

Diagnostic Testing Algorithm

For Suspected Gastrointestinal Etiology:

1. Initial approach: Trial of empiric acid suppression therapy with proton pump inhibitors (PPI) for suspected GERD 1, 2, 3
2. If symptoms persist despite PPI trial: Upper endoscopy to evaluate for esophagitis, eosinophilic esophagitis (requires biopsy), peptic ulcer disease, or gastritis 1, 3
3. If endoscopy normal and symptoms persist: Consider esophageal function testing (high-resolution manometry) and pH-impedance monitoring to identify motility disorders or confirm GERD 1, 3, 5

For Suspected Musculoskeletal Etiology:

• Physical examination with palpation of chest wall to reproduce pain is diagnostic 1, 2, 4
• Pain reproducible by palpation is more likely musculoskeletal than ischemic 6

For Suspected Pulmonary Etiology:

• Chest radiograph for pneumonia, pneumothorax, or pleural effusion 4
• Clinical prediction rules and D-dimer assay for pulmonary embolism risk stratification, followed by CT angiography if indicated 6

For Suspected Psychological Etiology:

• Screen with two-item questionnaire for panic disorder 6
• Consider this diagnosis in patients with recurrent similar presentations and repeatedly negative physiological workups 1

Management Strategy

Gastrointestinal-Related NCCP:

• GERD-related: Aggressive PPI therapy is standard of care and most effective treatment 3, 7
• Esophageal motility disorders: Consider medical interventions, endoscopic therapy, or surgical options depending on specific disorder 3
• Functional chest pain (negative diagnostic workup): Neuromodulators (tricyclic antidepressants, trazodone, SSRIs) are mainstay of therapy 3, 7

Musculoskeletal-Related NCCP:

• NSAIDs and physical therapy for costochondritis and muscle strain 2
• Address underlying cervical spine pathology if radiculopathy present 2

Psychological-Related NCCP:

• Cognitive-behavioral therapy is reasonable for patients with recurrent presentations and no physiological cause on prior diagnostic evaluation (Class 2a, Level B-R) 1
• Cognitive-behavioral therapy demonstrates 32% reduction in chest pain frequency 2
• Mixed evidence for antidepressants and anxiolytics, but neuromodulators should be considered 1, 3
• Address psychological comorbidities in all NCCP patients regardless of primary etiology 2, 3

Critical Clinical Pitfalls to Avoid

• Never assume non-cardiac chest pain is benign—some causes like pulmonary embolism remain life-threatening 2, 4
• Do not overlook psychological factors—these are common but frequently under-recognized, with clinician inquiry and referral rates <10% even when patients self-report anxiety 1
• Avoid premature attribution to anxiety before completing appropriate cardiac testing 2
• Do not use term "atypical chest pain" as it can be misinterpreted as benign; instead use "cardiac," "possibly cardiac," or "noncardiac" 1
• In women, recognize different pain descriptors—women more frequently use terms like "tearing" and experience pain in back, neck, and jaw 2
• For patients initially evaluated in office setting with suspected serious causes, avoid delayed transfer for troponin testing—transport urgently to ED by EMS (Class 3: Harm) 1

Special Populations

Older Patients (≥75 years):

• Consider ACS when accompanying symptoms include shortness of breath, syncope, acute delirium, or unexplained falls 1

Sickle Cell Disease:

• Emergency transfer by EMS to acute care setting is mandatory 1
• ACS must be excluded 1

Women:

• Women are at risk for underdiagnosis and potential cardiac causes must always be considered 1
• Obtain history emphasizing accompanying symptoms more common in women with ACS 1