What is the best approach to diagnose a patient with no pain, but experiencing fluttery feelings from the left upper abdomen to the epigastric and right chest under the breast, considering potential cardiac and gastrointestinal causes?

Diagnostic Approach to Fluttery Sensations from Left Upper Abdomen to Epigastric and Right Chest

Begin with a comprehensive cardiac evaluation using ECG and serial troponins, followed by focused assessment for diaphragmatic flutter and gastrointestinal causes if cardiac workup is negative.

Initial Cardiac Assessment

The absence of pain does not exclude cardiac pathology, and your symptoms warrant immediate cardiac evaluation given the distribution from epigastrium to chest 1.

Immediate Testing Required

• Obtain 12-lead ECG immediately to exclude acute coronary syndrome, arrhythmias, or pericarditis 1
• Serial troponin measurements at 6-12 hours from symptom onset are mandatory, as a single measurement is insufficient to exclude myocardial injury 2
• Repeat ECG if symptoms recur, as dynamic changes can indicate high-risk conditions even with initially normal findings 2

Consider Arrhythmia

Your "fluttery" sensation raises concern for paroxysmal supraventricular tachycardia (PSVT), particularly if episodes are intermittent 2:

• PSVT characteristically presents with palpitations, dizziness, and diaphoresis during episodes, with complete resolution at rest 2
• 24-48 hour Holter monitoring is indicated if palpitations occur frequently enough to capture during routine activities 3
• Event-activated ambulatory ECG recordings may reveal arrhythmias during symptomatic episodes if Holter monitoring is unrevealing 2

Structural Heart Disease Evaluation

• Echocardiography is essential to exclude structural abnormalities, valvular disease, or mitral valve prolapse that can present with similar sensations 2
• Upper abdominal and chest symptoms can represent atypical presentations of cardiac ischemia, particularly in women, diabetes, and elderly patients 1

Diaphragmatic Flutter Assessment

If cardiac workup is negative, diaphragmatic flutter becomes a primary consideration given your symptom distribution 4, 5:

Diagnostic Features

• High-frequency diaphragmatic flutter presents with epigastric pulsations, abdominal wall movements, and chest sensations without typical pain 4, 5
• Symptoms may include belching, hiccups, or retching sensations 5
• Diaphragmatic fluoroscopy confirms high-frequency flutter as the definitive diagnostic test 4

Confirmatory Testing

• Electromyography of the diaphragm showing repetitive discharges of 9-15 Hz establishes the diagnosis 5
• Spirographic tracings demonstrate high-frequency oscillations superimposed on tidal respiratory movements 5

Treatment if Confirmed

• Carbamazepine 200-400 mg three times daily leads to disappearance or significant improvement of flutter and symptoms 5

Gastrointestinal Evaluation

If cardiac and diaphragmatic causes are excluded, evaluate for gastrointestinal disorders 1:

Upper GI Assessment

• Upper endoscopy should be considered when esophageal causes are suspected, particularly if you have dysphagia, odynophagia, or unexplained symptoms 1
• Trial of empiric acid suppression therapy with proton pump inhibitors is reasonable if endoscopy is normal and symptoms persist 1, 6
• Esophageal function testing and pH monitoring should be considered if symptoms persist despite acid suppression 1

Key Gastrointestinal Considerations

• Gastroesophageal reflux disease is the most prevalent cause of noncardiac chest discomfort 6
• Esophageal spasm can mimic cardiac symptoms and may even respond to nitroglycerin, making it a diagnostic pitfall 1, 3

Psychological Factors Assessment

For recurrent symptoms with negative cardiac and GI workup, psychiatric evaluation is indicated 1, 3:

• Referral to cognitive-behavioral therapist is reasonable for recurrent presentations with no physiological cause on diagnostic evaluation 1
• Anxiety, panic disorder, and somatization commonly present with chest and epigastric sensations 1, 3, 6
• Cognitive-behavioral therapy has the highest level of evidence for anxiety disorders, with SSRIs or SNRIs as first-line medications 3

Critical Pitfalls to Avoid

• Never dismiss symptoms without cardiac evaluation, as upper abdominal pain and atypical chest sensations can represent myocardial ischemia, particularly in women 1, 3
• Do not rely on single troponin measurements drawn less than 6 hours from symptom onset 2
• Do not use nitroglycerin response as a diagnostic criterion, as esophageal spasm and other conditions also respond 1, 3
• Avoid overlooking diaphragmatic flutter, which requires high clinical suspicion and specific testing 4, 5

Algorithmic Approach Summary

1. ECG + serial troponins → If abnormal, pursue cardiac pathway
2. If cardiac negative + intermittent palpitations → Extended cardiac monitoring
3. If cardiac negative + persistent fluttering → Diaphragmatic fluoroscopy/EMG
4. If both negative → Upper endoscopy and trial of PPI
5. If all negative → Psychiatric evaluation and cognitive-behavioral therapy