Non-Cardiac Causes of Chest Heaviness
Gastrointestinal Causes
- Gastroesophageal reflux disease (GERD) is the most common esophageal cause of non-cardiac chest pain, often presenting as pressure or burning sensation 1
- Peptic ulcer disease may present with epigastric pain radiating to the chest 1
- Gastritis and other upper GI inflammatory conditions can mimic cardiac chest pain 2
Musculoskeletal Causes
- Costochondritis (inflammation of the cartilage connecting ribs to sternum) is the most common musculoskeletal cause, characterized by pain reproducible with palpation 1
- Cervical radiculopathy can cause pain radiating from the cervical spine to the chest 1
- Muscle strain or inflammation in chest wall muscles can create a sensation of heaviness 1
- Fibromyalgia can present with diffuse chest wall pain and heaviness 3
Pulmonary Causes
- Pulmonary embolism presents with tachycardia, dyspnea, and pain that worsens with inspiration in >90% of patients 1
- Pneumonia may cause localized pleuritic chest pain with friction rub 1
- Pneumothorax is characterized by pleuritic chest pain with unilateral decreased or absent breath sounds 1
- Pleuritis causes sharp pain that worsens with deep breathing 1
Psychological/Psychiatric Causes
- Anxiety disorders and panic attacks frequently present with chest tightness or heaviness and are often associated with other somatic symptoms 1, 4
- During anxiety, the sympathetic nervous system activation causes increased heart rate, blood pressure elevation, and muscle tension in the chest wall, creating a sensation of tightness or pressure 4
- Hyperventilation associated with anxiety can cause chest muscle spasms, contributing to the sensation of chest heaviness 4
- Somatoform disorders present with physical symptoms without identifiable organic cause 1
Other Causes
- Herpes zoster (shingles) affecting thoracic dermatomes can cause burning chest pain 1
- Sickle cell crisis may present with acute chest syndrome 1
- Aortic dissection presents with sudden onset of severe chest or back pain with pulse differential in 30% of patients 1
- Medication-related causes - NSAIDs, potassium supplements, iron, and bisphosphonates can cause esophageal irritation leading to chest discomfort 1
- Hormonal fluctuations during perimenopause can exacerbate anxiety symptoms, potentially worsening chest tightness 4
Diagnostic Approach
- Always begin by evaluating for life-threatening causes (aortic dissection, pulmonary embolism, esophageal rupture) 1
- For suspected GERD, a trial of empiric acid suppression therapy is recommended 1
- Consider upper endoscopy when an esophageal cause is suspected 1
- For persistent symptoms despite treatment, consider esophageal function testing and pH monitoring 1
- In patients with multiple similar presentations and negative cardiac workups, psychological factors should be addressed 1
Common Pitfalls to Avoid
- Assuming all non-cardiac chest pain is benign - some causes like pulmonary embolism and aortic dissection are life-threatening 1
- Failing to consider psychological factors - these are common but frequently overlooked 1, 4
- Premature attribution of chest pain to anxiety before appropriate cardiac testing has been completed 4
- Overlooking that women may describe chest pain differently than men, using terms like "tearing" more frequently and experiencing pain more often in the back, neck, and jaw 4, 5