Evaluation and Management of Chest Pain in Young Adults

Initial Approach to Chest Pain Evaluation

A focused cardiovascular examination should be performed initially to aid in diagnosing potentially serious causes of chest pain, such as acute coronary syndrome, aortic dissection, or pulmonary embolism, in patients with exercise-induced chest pain, according to the American Heart Association 1
Exercise-induced chest pain in a young adult requires careful evaluation as it may represent myocardial ischemia, even in patients without traditional risk factors, as recommended by the American College of Cardiology 2
Cultural competency training can help address potential biases that might lead to premature dismissal of symptoms as anxiety, particularly in diverse patient populations, as suggested by the American Heart Association and the American College of Cardiology 1, 3

Physical examination findings that suggest cardiac causes include tachycardia, abnormal heart sounds, or murmurs, though the exam may be normal in uncomplicated cases, according to the American Heart Association 1

For patients with recurrent chest pain presentations who have already had negative cardiac workups, referral to a cognitive-behavioral therapist is reasonable, with a Class 2a recommendation from the American College of Cardiology 2, 4

Premature attribution of chest pain to anxiety may lead to missed diagnoses of serious conditions, especially in younger patients who don't fit the typical cardiac profile, as warned by the American Heart Association and the American College of Cardiology 1, 3
Women and diverse patient populations are at particular risk for underdiagnosis when presenting with chest pain, according to the American College of Cardiology 3

Anxiety should only be considered as a cause of chest pain after appropriate cardiac testing has been completed and is negative, and other potential causes have been considered, as recommended by the American College of Cardiology and the American Heart Association 2, 4, 5

If cardiac causes are ruled out after appropriate testing, the clinician should discuss the findings with the patient and explain the relationship between anxiety and physical symptoms, as suggested by the American College of Cardiology and the American Heart Association 2, 5
For patients with recurrent chest pain and negative cardiac workups, referral for cognitive-behavioral therapy has shown a 32% reduction in chest pain frequency, according to the American Heart Association 5
Patients should be educated about when to seek emergency care for chest pain that differs from their typical pattern, as recommended by the American Heart Association 1