What is the best course of action for a 27-year-old female patient with intermittent chest pain for the past week, triggered by an anxiety-provoking event, with a normal electrocardiogram (ECG), and currently taking sertraline (selective serotonin reuptake inhibitor (SSRI)) for anxiety and depression?

Management of Anxiety-Related Chest Pain in a Young Woman on Sertraline

In this 27-year-old woman with intermittent chest pain triggered by an anxiety-provoking event and a normal ECG, the primary focus should be on optimizing anxiety management while ensuring cardiac causes are definitively excluded through troponin testing, followed by cognitive-behavioral therapy and potential adjustment of her sertraline regimen.

Immediate Cardiac Exclusion Required

Despite the clear anxiety trigger and young age, cardiac causes must still be systematically excluded before attributing symptoms entirely to anxiety 1, 2:

• Obtain cardiac troponin levels immediately (on admission and at 12 hours), as a normal ECG alone is insufficient—5-40% of patients with acute myocardial infarction present with a normal initial ECG 1
• Women are more likely than men to be inappropriately discharged with evolving myocardial infarction despite normal ECG findings 1
• The 12-lead ECG sensitivity for identifying ischemia is only 50%, making troponin testing essential 1

Risk Stratification Favoring Non-Cardiac Etiology

This patient has multiple features suggesting low cardiac risk 2, 3:

• Age 27 years places her at extremely low pretest probability for coronary disease (women aged 30-39 with typical angina have only 26% probability) 2
• Clear temporal relationship between anxiety-provoking trigger and symptom onset 1
• Intermittent nature over one week without progression suggests against acute coronary syndrome 1
• Normal ECG significantly reduces short-term mortality risk 1

Psychiatric Etiology as Primary Diagnosis

Once troponins are confirmed negative, this presentation is consistent with anxiety-related chest pain 1:

• Noncardiac chest pain has close association with anxiety, panic disorder, depression, and somatoform disorders, with mechanisms including central nervous system-visceral interactions, low pain thresholds, and sympathetic activation 1
• In low-risk chest pain patients without cardiac disease, depression and anxiety each exceed coronary artery disease by almost 10-fold 1
• Chest pain in coronary heart disease patients predicts more severe anxiety and depression symptoms, but anxiety itself has only limited effects on causing chest pain 4

Treatment Algorithm

Step 1: Reassurance and Education

• Provide definitive reassurance once troponins are negative, as demonstration of normal cardiac workup reduces hospitalization needs and healthcare utilization 1
• Explain that prognosis is devoid of cardiac complications in noncardiac chest pain 1

Step 2: Optimize Sertraline Therapy

• Sertraline is effective for panic disorder and mixed anxiety-depression at doses of 50-175 mg daily 5, 6
• Assess current dose and consider titration if subtherapeutic 5
• Sertraline reduces severity and frequency of panic attacks and baseline anxiety 5
• Note: Sertraline can rarely cause pleuritic chest pain from interstitial lung disease, though this typically presents with cough, hypoxia, and ground-glass opacities on imaging 7

Step 3: Cognitive-Behavioral Therapy

• Refer for cognitive-behavioral therapy, which shows 32% reduction in chest pain frequency over 3 months in patients with chest pain and psychological disorders 1
• Cognitive-behavioral approaches are most effective among psychotherapy modalities 1
• Low rates (<10%) of clinician referral for psychological factors represent a missed therapeutic opportunity 1

Step 4: Adjunctive Pharmacotherapy if Needed

• If symptoms persist despite optimized sertraline, consider beta-blockers (effective in reducing chest discomfort episodes in syndrome X) 1
• Imipramine 50 mg daily reduces chest pain frequency by 50% in chronic pain syndromes 1
• Avoid benzodiazepines for chronic management despite their anxiolytic properties 6

Critical Pitfalls to Avoid

• Do not skip troponin testing based solely on age and anxiety history—women are at higher risk of missed acute coronary syndrome 1, 2
• Do not allow extensive repetitive cardiac testing once initial workup is definitively negative, as this reinforces illness behavior and delays appropriate psychiatric treatment 1
• Do not dismiss the patient without addressing the underlying anxiety disorder, as untreated anxiety leads to continued healthcare utilization and disability 1, 5
• Recognize that associated symptoms like nausea and anxiety can occur with both cardiac and non-cardiac chest pain 1

Return Precautions

Instruct the patient to return immediately for 1, 2:

• Chest pain with diaphoresis, nausea, or radiation to arm/jaw
• Dyspnea at rest
• Syncope or presyncope
• Chest pain lasting >20 minutes despite rest

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