Chest pain that's not heart attack
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8 papers analyzed
These studies suggest that non-cardiac chest pain can be caused by conditions such as gastroesophageal reflux, esophageal disorders, muscle strains, infections, and psychological factors, and requires multidisciplinary management for effective treatment.
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Understanding Non-Cardiac Chest Pain: Causes, Diagnosis, and Management
Introduction to Non-Cardiac Chest Pain (NCCP)
Non-cardiac chest pain (NCCP) is a type of chest pain that mimics the symptoms of a heart attack but is not related to heart disease. It is characterized by angina-like discomfort without evidence of coronary artery disease . This condition is prevalent, affecting up to 70% of patients presenting with chest pain in various healthcare settings.
Common Causes of Non-Cardiac Chest Pain
Gastroesophageal Reflux Disease (GERD)
GERD is the most common cause of NCCP, accounting for 50-60% of cases. It occurs when stomach acid flows back into the esophagus, causing a burning sensation in the chest . Symptoms often include heartburn and regurgitation of stomach contents.
Esophageal Motility Disorders
Esophageal motility disorders, such as nutcracker esophagus, diffuse esophageal spasm, and achalasia, contribute to 15-18% of NCCP cases. These conditions involve abnormal muscle contractions in the esophagus, leading to chest pain .
Musculoskeletal Causes
Musculoskeletal issues, such as costochondritis (inflammation of the cartilage connecting the ribs to the breastbone), can also cause chest pain. This type of pain is often exacerbated by physical activity or certain movements.
Psychiatric Conditions
Psychiatric conditions, including panic disorder and anxiety, are significant contributors to NCCP. Panic attacks can present with chest pain that is often mistaken for a heart attack, leading to high healthcare utilization and psychological distress .
Pulmonary Causes
Pulmonary conditions, such as pleurisy (inflammation of the tissue lining the lungs) and bronchitis, can also cause chest pain. These conditions are often associated with coughing and respiratory symptoms.
Diagnosis of Non-Cardiac Chest Pain
Initial Evaluation
All patients presenting with chest pain should initially be evaluated by a cardiologist to rule out cardiac causes. This typically involves a thorough history, physical examination, and diagnostic tests such as electrocardiograms (ECGs) and coronary angiography.
Gastroenterological Assessment
If cardiac causes are excluded, a gastroenterological assessment is often necessary. This may include endoscopy, high-resolution manometry to assess esophageal motility, and pH monitoring to detect abnormal acid exposure in the esophagus.
Psychological Evaluation
Given the high prevalence of psychiatric comorbidities in NCCP patients, a psychological evaluation may be warranted. This can help identify conditions such as panic disorder and anxiety, which may require specific treatment .
Management of Non-Cardiac Chest Pain
GERD Management
For GERD-related NCCP, proton pump inhibitors (PPIs) are the first-line treatment. A therapeutic trial of PPIs for 2-4 weeks is often recommended to assess response.
Treatment of Esophageal Motility Disorders
Management of esophageal motility disorders may include smooth muscle relaxants, neuromodulators, and in some cases, surgical or endoscopic interventions.
Psychological Interventions
Psychological interventions, including cognitive-behavioral therapy (CBT) and the use of selective serotonin reuptake inhibitors (SSRIs), are effective in managing chest pain related to panic disorder and anxiety .
Multidisciplinary Approach
A multidisciplinary approach is crucial for the effective management of NCCP. Regular interdisciplinary ward rounds and collaboration between cardiologists, gastroenterologists, and mental health professionals can improve patient outcomes.
Conclusion
Non-cardiac chest pain is a complex condition with various underlying causes, including GERD, esophageal motility disorders, musculoskeletal issues, psychiatric conditions, and pulmonary diseases. Accurate diagnosis and a multidisciplinary approach to management are essential for improving patient outcomes and quality of life. By addressing the specific etiology of NCCP, healthcare providers can offer targeted treatments that alleviate symptoms and reduce the burden on healthcare resources.
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