How should I evaluate and manage a 36-year-old woman presenting with chest and neck discomfort and dizziness when cardiac causes have been excluded?

Evaluation and Management of Chest and Neck Discomfort with Dizziness in a 36-Year-Old Woman (Cardiac Causes Excluded)

Once cardiac causes are definitively excluded, focus your evaluation on gastrointestinal disorders (particularly gastroesophageal reflux disease), musculoskeletal causes, neurological conditions, and psychological factors, as these account for the majority of noncardiac chest pain cases. 1

Systematic Differential Diagnosis Approach

Gastrointestinal Causes (Most Common)

Gastroesophageal reflux disease (GERD) is the most prevalent cause of noncardiac chest pain and should be your first consideration. 1

• GERD characteristics: Burning retrosternal discomfort that may radiate to the neck, often positional (worse when lying supine), associated with regurgitation, sour taste, or dysphagia 2, 1
• Diagnostic approach: Empiric trial of high-dose proton pump inhibitor (omeprazole 20-40 mg once daily before meals) for 2-4 weeks is both diagnostic and therapeutic, with 80-90% response rate if GERD is the cause 3, 1
• Esophageal spasm: Can mimic angina with substernal chest pain that may respond to nitroglycerin, making it particularly confusing; consider if pain is sharp, sudden onset, and associated with swallowing 2

Musculoskeletal Causes

• Costochondritis: Sharp, localized chest pain that is reproducible with palpation of the chest wall or specific movements 2
• Positional chest pain: Pain that changes with body position or arm movement is typically nonischemic and suggests musculoskeletal origin 2
• Cervical radiculopathy: Neck discomfort radiating to chest, often with positional component and may be associated with arm symptoms 4

Neurological Causes

Neurological etiologies are frequently overlooked but can present with chest pain and dizziness. 4

• Migraine: Can present with chest pain as part of the symptom complex, often accompanied by headache, visual changes, or dizziness 4
• Epilepsy: Rarely presents with chest pain but should be considered if there are associated neurological symptoms 4
• Peripheral neuropathy: May cause atypical chest sensations 4

Psychological and Psychiatric Factors

Psychological conditions such as panic disorder, anxiety, and depression are present in a significant proportion of patients with noncardiac chest pain and may cause or worsen symptoms. 1

• Panic disorder: Sudden onset chest discomfort with palpitations, dizziness, shortness of breath, sense of impending doom, lasting minutes to hours 1
• Depression: May amplify pain perception and is often underdiagnosed in patients with chest pain 1
• Hyperventilation syndrome: Can cause chest tightness, dizziness, and paresthesias 1

Specific Evaluation Strategy

History Elements to Obtain

• Relationship to meals: Pain occurring 30-60 minutes after eating or when lying down suggests GERD 1
• Reproducibility with palpation or movement: Indicates musculoskeletal cause 2
• Duration and pattern: Fleeting pain (seconds) is unlikely to be serious; sustained pain (hours) may suggest GERD or anxiety 2, 1
• Associated symptoms: Regurgitation, dysphagia (GERD); numbness/tingling (hyperventilation); sense of doom (panic disorder) 1
• Stress relationship: Symptoms triggered by emotional stress without physical exertion suggest psychological factors 1

Physical Examination Focus

• Chest wall palpation: Reproduce pain by pressing on costochondral junctions or intercostal spaces 2
• Neck examination: Assess for cervical spine tenderness, range of motion limitations, or radicular signs 4
• Neurological examination: If dizziness is prominent, assess for nystagmus, gait abnormalities, or focal deficits 4

Diagnostic Testing Algorithm

For a 36-year-old woman with definitively excluded cardiac causes, avoid unnecessary testing and pursue targeted evaluation based on clinical suspicion. 2

1. First-line approach: Empiric trial of high-dose PPI therapy for 2-4 weeks 3, 1

   • If symptoms resolve: Diagnose GERD and continue therapy
   • If symptoms persist: Proceed to step 2

2. If PPI trial fails and symptoms suggest esophageal disorder: Upper endoscopy to evaluate for esophagitis, stricture, or other structural abnormalities 3

3. If musculoskeletal features predominate: Trial of NSAIDs and physical therapy; consider cervical spine imaging if neck symptoms are prominent 4

4. If neurological symptoms are present: Neurology consultation and consider brain MRI if migraine or other CNS pathology suspected 4

5. If psychological factors suspected: Screen for depression (PHQ-9) and anxiety disorders; consider psychiatry or psychology referral 1

Management Approach

Symptomatic Treatment

• For nausea/dizziness: Ondansetron 8 mg sublingual every 4-6 hours or promethazine 12.5-25 mg every 4-6 hours 3
• For GERD: High-dose PPI (omeprazole 20-40 mg once daily) before meals 3
• For musculoskeletal pain: NSAIDs (ibuprofen 400-600 mg three times daily with food) and physical therapy 2
• For anxiety-related symptoms: Consider low-dose tricyclic antidepressant (imipramine 50 mg daily) which has been shown to reduce chest pain frequency by 50% in chronic pain syndromes 2

Reassurance and Patient Education

Provide explicit reassurance about the excellent prognosis when cardiac causes are excluded, as this alone can reduce symptom frequency and severity. 2

• Explain that noncardiac chest pain, while uncomfortable, does not indicate life-threatening disease 2, 1
• Discuss the high prevalence of GERD and musculoskeletal causes in young women 1
• Address any specific concerns about cardiac disease that may be perpetuating anxiety 1

Critical Pitfalls to Avoid

• Do not assume cardiac workup was adequate: Verify that appropriate testing was performed, including ECG, cardiac biomarkers (high-sensitivity troponin), and risk stratification 2
• Do not dismiss symptoms in women: Women are at risk for underdiagnosis of cardiac causes and may present with atypical symptoms; ensure cardiac evaluation was thorough 2, 5
• Do not overlook psychological comorbidities: Depression and anxiety are frequently present but underdiagnosed in patients with chest pain and significantly impact symptom severity 1
• Do not order extensive testing without clinical indication: For low-risk patients with noncardiac chest pain, avoid unnecessary imaging and invasive procedures 2

Follow-Up Strategy

• Short-term follow-up (2-4 weeks): Assess response to empiric therapy and adjust treatment accordingly 3, 1
• If symptoms persist despite treatment: Consider referral to gastroenterology for esophageal motility studies or pH monitoring 1
• Long-term management: Address any identified psychological factors with appropriate therapy or referral 1