Management of Resolved Chest Pain with Psychiatric Etiology
For this 49-year-old male with resolved chest pain following lithium discontinuation and lamotrigine initiation, no further cardiac workup is needed; instead, refer to cognitive-behavioral therapy and ensure appropriate psychiatric follow-up. 1
Rationale for Non-Cardiac Etiology
The clinical presentation strongly suggests anxiety-related chest pain rather than acute coronary syndrome based on several key features:
- Clear temporal relationship: The chest pain began specifically when the patient was transferred to segregation for disciplinary issues, establishing a direct psychological trigger 1
- Complete symptom resolution: The pain completely resolved after psychiatric medication adjustment (discontinuing lithium and starting lamotrigine), which would not occur with true cardiac ischemia 1
- Atypical pain characteristics: The patient can pinpoint the exact location of discomfort, and the pain migrates from chest to shoulder (disappearing from one location as it appears in another), which is inconsistent with cardiac ischemia 2
- Normal cardiac evaluation: The ECG was normal, and importantly, no recurrent episodes have occurred since the psychiatric intervention 1
Why Additional Cardiac Testing Is Not Indicated
Do not pursue further cardiac workup in this patient. The combination of normal ECG, complete symptom resolution with psychiatric treatment, and clear psychological trigger makes the probability of cardiac disease extremely low 1. In low-risk chest pain patients without evidence of cardiac disease, depression and anxiety each exceed coronary artery disease by almost 10-fold 1. Pursuing repetitive cardiac testing in this context reinforces illness behavior, delays appropriate psychiatric treatment, and exposes the patient to unnecessary cost and potential harm 1.
Recommended Management Algorithm
Immediate Actions (This Visit)
- Provide definitive reassurance: Explicitly tell the patient that his cardiac workup is normal and his symptoms are not cardiac in origin 1
- Document psychiatric etiology: Clearly note in the medical record that chest pain resolved with psychiatric medication adjustment, supporting non-cardiac diagnosis 1
- Verify medication compliance: Confirm the patient is taking lamotrigine 25mg as prescribed and assess for any side effects 1
Referrals Required
- Cognitive-behavioral therapy referral: This is the most effective treatment modality, showing a 32% reduction in chest pain frequency over 3 months in patients with chest pain and psychological disorders 1
- Psychiatric follow-up: Ensure the patient has scheduled follow-up with the mental health team to monitor response to lamotrigine and adjust dosing as needed 1
Patient Education on Return Precautions
Instruct the patient to return immediately only if he experiences:
- Chest pain with diaphoresis, nausea, or radiation to arm/jaw 3
- Dyspnea at rest 3
- Syncope or presyncope 3
- Chest pain lasting >20 minutes despite rest 3
Critical Pitfalls to Avoid
Do not order serial troponins, stress testing, or cardiology referral in this patient with resolved symptoms and clear psychiatric etiology, as this perpetuates unnecessary healthcare utilization 1. The prognosis of patients with noncardiac chest pain is largely devoid of cardiac complications 1.
Do not dismiss the underlying psychiatric condition: Untreated anxiety leads to continued healthcare utilization and disability 3. The fact that symptoms resolved with psychiatric medication adjustment confirms the diagnosis and demonstrates the importance of addressing the underlying mental health condition 1.
Avoid using nitroglycerin response as a diagnostic test if symptoms recur, as esophageal spasm and other noncardiac conditions also respond to nitroglycerin 2