Noncardiac chest pain
A rational approach to
a common complaint
Identifying noncardiac chest pain early and treating it effectively
can relieve some of the enormous burden this complaint places
on the health care system and the patient alike.
Gregory S. Watson, PA-C
than $8 billion in health care costs annually,2 with car-
hest pain is significant not only because of the
health problem it might indicate but also because diac causes found in only 20% of admissions.3 Even after
of how much it costs the health care system and removing patients with known cardiac disease, a popu-
how greatly it affects the lives of patients. Most persons lation-based study in Australia revealed that 33% of the
who are evaluated in a primary care setting will have a polled population had had noncardiac chest pain
noncardiac cause of their symptoms.1 Even so, the im- (NCCP) at some time.2 Conservatively extrapolated to
portance of ruling out possible cardiac pathology usual- the US population, this could mean up to 80 million pa-
ly leads to expensive and complicated workups. tients presenting to clinics with NCCP.2
Accurately diagnosing and treating patients with
Incidence and prevalence musculoskeletal, GI, psychological, and other causes for
In the United States, the complaint of chest pain leads NCCP can be challenging. Nevertheless, all possible
to more than 6 million hospital admissions and more causes should be explored because patients with NCCP
can have significant long-term morbidity due to their
CME Earn Category I CME credit by reading this
article and the article beginning on page 26
pain.2 All practitioners should assess for cardiac disease
and be aware of the variety of noncardiac causes of
chest pain in order to begin appropriate therapy.
and successfully completing the post-test on
page 33. Successful completion is defined as a
cumulative score of at least 70% correct. Diagnosing nonspecific chest pain
This material has been reviewed and is approved for Evaluate all patients presenting with chest pain initial-
1 hour of clinical Category I (Preapproved) CME credit by the AAPA.
The term of approval is for 1 year from the publication date of
ly for possible cardiac causes. A careful, thorough
January 2006. history looking for cardiac risk factors, followed by a
12-lead ECG, chest radiograph, and serial measure-
Learning objectives ments of cardiac enzymes, should help determine
• Review the initial evaluation of chest pain whether the patient’s pain is cardiac in nature.4 If the
• Discuss the anatomic dysfunction and other patient is stable and the etiology is still unclear, refer-
causes responsible for musculoskeletal, GI, ral for a cardiology consult, echocardiography, or stress
and psychological chest pain ECG is warranted.4
• List the key components of the history and physi- Once a cardiac cause has been ruled out, consider the
cal examination that will help distinguish cardiac differential diagnosis for chest pain. A survey of pri-
from noncardiac chest pain
• Describe the most effective way to diagnose and
treat each type of chest pain The author works in a pulmonary medicine and critical care pri-
vate practice in Iowa City, Iowa. He has indicated no relation-
ships to disclose relating to the content of this article.
20 JAAPA VOL.19, NO. 1 JANUARY 2006 www.jaapa.com
Studies have shown
that noncardiac chest
pain most frequently
has a musculoskeletal,
mary care centers in Michigan revealed that musculo- History and physical examination
skeletal conditions were responsible for 36% of cases of Any history of new or excessive physical activity is
chest pain, followed by GI (19%), nonspecific (16%), psy- important, as are trauma to the thorax, shoulder, or
chiatric (7.5%), and pulmonary (5%) conditions.1 The back or a history of rheumatic diseases, such as rheuma-
three most common misunderstood causes of NCCP are toid arthritis, ankylosing spondylitis, psoriatic arthritis,
musculoskeletal, GI, and psychosocial. fibromyalgia, or sternocostoclavicular hyperostosis. A
history of a cough or dyspnea can indicate musculo-
MUSCULOSKELETAL CAUSES skeletal chest pain from intercostal muscle strain.
Fractures of any of the bones of the thoracic wall can Musculoskeletal pain tends to have a deep, aching qual-
cause chest pain, as can localized inflammation or dislo- ity that is hard to localize. Questions about systemic
cation of the costosternal, sternoclavicular, or costo- signs such as weight loss and night sweats are impor-
chondral joints due to traumatic, rheumatic, or idiopath- tant to rule out serious illnesses.6
ic conditions. Strains of the pectoralis or intercostal The physical evaluation should begin with observa-
muscles may cause pain, while muscle or joint pain from tion of the chest wall for obvious deformities or inflam-
the shoulders or spine can also be referred to the chest.5 mation. The hallmark of musculoskeletal chest pain is
In particular, low cervical spine and T1 nerve roots sup- pain that is reproducible with palpation or with active/
ply the pectoralis muscles, and while they more com- passive range of motion (ROM) movements of the joints
monly refer pain to the scapulae, they can cause chest and musculature of the affected area. Palpate and use
pain.6 Herpes zoster infection may also have a prodrome such ROM exercises to test areas with potential for
of severe unilateral chest pain that radiates along a referred pain, such as the cervical and thoracic spine.
dermatome. Consider the diagnosis of fibromyalgia, particularly
www.jaapa.com VOL.19, NO. 1 JANUARY 2006 JAAPA 21
Noncardiac chest pain
ful. If a joint infection is suspected, a CBC, Gram’s stain,
IN THIS ARTICLE and culture of joint aspirate should be ordered.7
® The most common causes of noncardiac chest For most patients with musculoskeletal chest pain, edu-
pain are musculoskeletal, GI, and psychological.
cation to relieve anxiety is part of the first-line treatment.
® A careful history and physical examination, along The patient should suspend or limit any activities that
with selected ancillary tests, can determine the
source of the patient’s pain and point the way to a exacerbate the pain and expect a gradual resolution of
specific, effective treatment regimen. symptoms over time. NSAIDs are useful to manage pain
® Support and reassurance are important corner- and reduce mild inflammation.8 Most severe, acute caus-
stones in the management of noncardiac chest es of musculoskeletal chest pain, such as rib fracture, can
pain. be managed with short-term use of opioids such as hy-
drocodone or oxycodone. Inflammatory diseases like cos-
Competencies tochondritis can be safely and successfully treated with
Medical knowledge NNNNN joint injections of triamcinolone plus 1% lidocaine.9 Tri-
cyclic antidepressants (TCAs) are useful in treating gen-
Interpersonal & communication skills NNNN eralized pain and are particularly effective for neurogenic
Patient care NNNN pain, such as that from herpes zoster.10 Herpes zoster
infections should be treated with an antiviral agent such
as acyclovir, valacyclovir, or famciclovir within 48 to 72
Practice-based learning and improvement N hours of the eruption to limit the outbreak’s duration.11
Systems-based practice N
For an explanation of competencies ratings, see the table of contents. Gastroesophageal reflux disease (GERD) can cause
substernal chest pain and is the most common cause of
GI-associated chest pain.12 Abnormalities in esophageal
with the discovery of trigger points, in female patients function can produce chest pain and exacerbate GERD.
younger than 60 years who present with concomitant Studies using esophageal manometry to evaluate pa-
psychiatric issues, sleep problems, or chronic muscle tients with NCCP have found hypotensive tone of the
pain. Specific pain syndromes such as costochondritis lower esophageal sphincter (LES) to be the most com-
usually have multiple tender costosternal joints with mon abnormality. A decrease in sphincter tone allows
minimal swelling, while Tietze’s syndrome usually man- gastric contents and acid to reflux back into the esoph-
ifests with one particularly painful joint and significant agus, causing irritation to the esophageal lining, which
local swelling.6 A thorough clinical examination of the may be perceived as chest pain.13 Recent research sug-
heart, lungs, and abdomen is also necessary. Pay partic- gests that patients with GERD can have a CNS-medi-
ular attention to the skin since herpes zoster and psori- ated hypersensitivity to the acid irritation that results
atic arthritis can have associated rashes and can cause in a longer and more severe sensation of chest pain.14
musculoskeletal chest pain.7 Abnormal contractions of portions of the esophagus
can also cause chest pain. Nutcracker esophagus is one
Diagnosis of the most common and is due to high-amplitude con-
If palpation or active/passive ROM movements of the tractions of the distal esophagus. The etiology of these
area of discomfort reproduce the pain, the pain is likely to contractions is unknown, but acid irritation of the
be musculoskeletal. No other tests may be necessary in esophageal mucosa has been implicated. Another con-
patients without risk factors or a history that suggests traction abnormality is hypertensive LES pressure,
systemic illnesses or fractures. Posteroanterior and lat- which has been found in 10% of patients with NCCP and
eral chest radiographs are cost-effective ways to identify abnormal manometry results.13 Another 10% of this
dislocations or solid tumors, and CT can be particularly group have nonspecific esophageal motor disorders that
useful in elucidating sternal or sternoclavicular structure can be caused by peristaltic abnormalities such as non-
as well as soft tissue swelling. An elevated ESR may transmitted or retrograde contractions and incomplete
indicate a rheumatic process in a patient with other clin- LES relaxation. Other causes are achalasia (absence of
ical signs, such as myalgias and joint tenderness. Should LES relaxation with swallowing) and diffuse esoph-
the patient’s clinical picture and history warrant it, fur- ageal spasms of 20% to 100% of the esophageal muscu-
ther workup with more specific tests, such as those for lature.15 Less common esophageal abnormalities are
antinuclear antibodies or rheumatoid factor, may be help- Mallory-Weiss tears and Zenker’s diverticulum of the
22 JAAPA VOL.19, NO. 1 JANUARY 2006 www.jaapa.com
esophagus. Cholecystitis and pancreatitis can also cause tests can be useful in more atypical cases. While they
chest pain and left shoulder discomfort because of have limited sensitivity, tests for amylase and lipase
diaphragmatic or phrenic nerve irritation. levels can be useful in diagnosing pancreatitis, and
serum Helicobacter pylori testing can be helpful if the
History and physical examination pain is thought to be due to peptic ulcer. CT can aid in
Since GERD is the most common cause of GI-associated the diagnosis of pancreatitis when amylase and lipase
chest pain, questions that tease out this possible diagno- levels are indeterminate or do not match the clinical
sis are important. A history of heartburn is a significant picture. Ultrasonography is the diagnostic test of
risk factor, independent of other GI complaints, age, and choice for biliary pathology, followed by CT in uncer-
gender. Dysphagia and acid regurgitation are also signif- tain cases.20
icant risk factors, although not independently predictive.2
Ask whether the pain is associated with supine or prone Treatment
positions and if it occurs postprandially or after eating Respond to patients who have GI-associated NCCP
spicy or fatty foods, all of which can suggest GERD. with reassurance that the pain is probably not cardiac.
A history of dysphagia can indicate possible esoph- Encourage the patient to reduce fat intake, avoid foods
ageal motility dysfunction or, in association with late that cause reflux, and stop smoking.17 While omeprazole
regurgitation, Zenker’s diverticulum.12,13 Mallory-Weiss has been the only PPI tested, any PPI should be effec-
tears are the most common lacerations of the esophagus tive as a first-line treatment for GERD-related NCCP.17
and are associated with chronic alcohol abuse and with Studies show that omeprazole significantly decreases
severe vomiting or coughing. An abrupt onset of chest the number and severity of chest pain episodes.17 Start
pain while vomiting or coughing and subsequent with double the usual dosage, titrating down to the low-
hematemesis are characteristic.16 est effective dosage for long-term administration.17
The physical examination, although important, is Laparoscopic fundoplication is 85% to 90% effective in
somewhat limited in chest pain with a GI source. It reducing chest pain, but it carries with it the complica-
should include a thorough abdominal examination not- tions and cost of surgery and should not be a first-line
ing particular tender points, especially those along the treatment.17
epigastrium, that could indicate peptic ulcer disease,
pancreatitis, or Murphy’s sign. A digital rectal examina-
tion and stool guaiac test can help determine whether A relationship between certain
GI bleeding is present.
psychological disorders and
Ambulatory 24-hour esophageal pH monitoring can iden- noncardiac chest pain has long
tify GERD-associated chest pain with 60% to 90% sensi-
tivity and 85% to 100% specificity.17 However, this test is been recognized.
expensive, invasive, and not always available. A 2-week
course of moderate to high doses of a proton pump
inhibitor (PPI) is an effective and cost-saving test, with Pain from suspected esophageal dysmotility disor-
71% to 90% sensitivity and 67% to 88% specificity.17,18 If a ders tends to respond well to low dosages of imipramine
PPI reduces or resolves the pain, GERD is likely the and trazodone.19 A small study showing significant im-
cause. If a PPI does not reduce the pain or does so only provement in chest pain symptoms with the use of ser-
minimally, a referral for ambulatory esophageal pH mon- traline opens the possibility of using selective serotonin
itoring is advised.19 Ambulatory monitoring is advanta- receptor inhibitors (SSRIs) to control NCCP.21 Several
geous because spikes in esophageal pH can be correlated studies have tested whether calcium channel blockers
with the patient’s symptoms. Barium swallows and are effective against confirmed dysmotility disorders.
upper endoscopy are poor diagnostic tests for GERD- While they have shown some promise, their use has
related chest pain and should be used only when other been controversial.19 Endoscopic band ligation and
tests are nondiagnostic or when Mallory-Weiss tears or injections of epinephrine are effective treatments for
Zenker’s diverticulum is suspected. Esophageal manom- Mallory-Weiss tears, and endoscopy or open surgery
etry may be useful in patients with suspected esophageal can be used to treat Zenker’s diverticulum.22,23
dysmotility or dysphagia, although correlation between
dysmotility and chest pain events is only 20% to 30%.17 PSYCHIATRIC DISORDERS
Laboratory tests do not generally help to diagnose A relationship between certain psychological disorders
the more common GI causes of NCCP, but certain blood and NCCP has long been recognized. Among patients
www.jaapa.com VOL.19, NO. 1 JANUARY 2006 JAAPA 23
Noncardiac chest pain
presenting to both inpatient and outpatient cardiology marked by long-term worry or anxiety, may include
services for chest pain, 25% to 56% have panic disorder, restlessness, easy tiring, muscle tension, sleep distur-
the most common psychological malady associated with bances, and irritability.27 OCD and major depressive
NCCP.24 Of patients with NCCP, 15% to 60% have asso- disorder are less common causes of NCCP. Ask ques-
ciated panic disorder.24 tions about irritable bowel syndrome, other psychiatric
While the mechanisms behind the physiology of psy- illnesses, and the family history of psychiatric illness-
chiatric NCCP are not clear, several studies have es.19 Panic disorder that manifests as chest pain tends to
shown a relationship between hyperventilation, which affect women younger than 30 years with no family his-
is known to induce panic attacks, and esophageal tory of cardiac disease, but anyone can be affected.25
spasms.25 The theory is that these spasms are the Pay special attention to signs of self-abuse or illicit drug
chest pains experienced by the patient. However, car- use that could also indicate mental illness or depression.
bon dioxide is known to induce panic and cause chest A complete physical examination, while necessary, is
pain, but it does so without effect on the esophagus generally not helpful in diagnosing psychiatric causes of
and its physiology remains unclear. Since panic causes chest pain.
an imbalance in several areas of the CNS, including
the serotonin and noradrenergic systems, centrally Diagnosis
mediated visceral hypersensitivity may also play a Several questionnaires are available to help with screen-
role.19 A hypersensitivity to visceral pain, particularly ing. The Hospital Anxiety and Depression Scale (HADS),
esophageal, could trigger the classic panic cycle of anx- the Patient Health Questionnaire (PHQ), and a screening
iety: catastrophic misunderstanding of symptoms, question that simply asks if the patient has ever had a
leading to more anxiety, leading to more misunder- sudden feeling of anxiety or panic all have good sensitivi-
standing, leading to further anxiety, and so forth.24 ty and specificity in identifying panic disorder. Although
Generalized anxiety disorder, obsessive-compul- the single question had only 78% specificity, at 93% sensi-
sive disorder (OCD), and major depressive disorder tivity it is probably the most efficient screening tool avail-
have also been implicated as contributors to NCCP, able.28 If a patient is exhibiting severe symptoms of one or
but to a much lesser degree.26 Little is known about more of these disorders, or if the provider is uncomfort-
the physiology of the chest pain associated with these able managing these issues, then the patient should be re-
disorders. ferred to a mental health specialist.
Benzodiazepines work quickly and When a patient’s chest pain has a psychiatric cause, reas-
surance and encouragement are vital. The patient may re-
effectively in patients with panic quire regular clinic follow-up. In addition to reassurance,
both antidepressants and cognitive behavior therapy
disorder and concomitant NCCP, but (CBT) are effective and can be used simultaneously.24
Pharmacotherapeutic possibilities include trazo-
use should generally be short term. done, imipramine, benzodiazepines, and SSRIs, al-
though trazodone or imipramine in low dosages are
preferred.29 Trazodone, 25 to 50 mg at bedtime, re-
History and physical examination duces symptoms of NCCP and insomnia.29 Imipramine
When assessing a patient with possible psychogenic (25 mg) significantly decreases NCCP regardless of
chest pain, rule out potential cardiac causes first. After coexisting esophageal or psychiatric illnesses, but
reasonable assurance that the cardiovascular system is it has significant anticholinergic side effects.24 Benzo-
not causing the pain, questions concerning the patient’s diazepines work quickly and effectively in patients
mental health are appropriate. with panic disorder and concomitant NCCP, but use
Ask direct, specific questions about the symptoms of should generally be short term to avoid physical
panic disorder: brief, intense feelings of doom, profuse dependence. One approach to managing patients with
sweating, dizziness, palpitations, shortness of breath, severe panic disorder and NCCP is to prescribe a
paresthesias, or a sensation of choking. Patients with short course of a low-dose benzodiazepine until the
panic disorder may have agoraphobia or other phobias patient can be seen by a mental health professional
regarding certain places or situations. Questions about for further care.19 SSRIs have a more encouraging
recent stressors such as job loss, divorce, or the death of side-effect profile than benzodiazepines, although
a loved one can be helpful in assessing a patient’s cur- only one small study found them effective in patients
rent psychological state.24 Generalized anxiety disorder, with NCCP.21
24 JAAPA VOL.19, NO. 1 JANUARY 2006 www.jaapa.com
CBT is also useful for treating NCCP. Studies show NCCP are five times more likely to present to a
that treated patients have a 48% to 80% improvement provider than are patients with severe NCCP.2,3,30 Not
in symptoms over control populations and that these only do these patients present more often, but the
improvements persist for at least 2 years after cessa- majority will continue to have pain 5 years after being
tion of therapy.19,24 seen and have a significantly worse quality of life based
on the severity of their pain.2
Conclusion The burden on both the medical system and the
Patients with NCCP rarely fit neatly into one of the patient with NCCP is significant. The clinician should
previously discussed categories. Indeed, NCCP often take care to rule out potential cardiac causes of chest
has multiple causes, and the clinician should bear this pain, particularly in patients with known risk factors.
in mind. For patients with atypical chest pain and few Just as important, however, is being prepared to identi-
cardiac risk factors, questions designed to elicit a psy- fy and treat the more common causes of NCCP. I
chiatric cause for the pain might be asked early in the
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