Physiological Mechanisms

The American College of Cardiology suggests that anxiety triggers the sympathetic nervous system, causing increased heart rate, blood pressure elevation, and muscle tension in the chest wall, creating a sensation of tightness or pressure 1, 2
The close association between chest pain and psychological syndromes such as anxiety, panic attacks, depression, and cardiophobia suggests a psychogenic origin in many patients, as noted by the American College of Cardiology and Circulation 1, 3
Specific mechanisms for anxiety-related chest pain include central nervous system-visceral interactions, as described in Circulation 2, 3
Heightened body vigilance and lowered pain thresholds are also contributing factors, according to the American College of Cardiology and Circulation 1, 2
Sympathetic activation causing cardiovascular changes is another mechanism, as suggested by the American College of Cardiology and Circulation 1, 3
Hyperventilation can cause chest muscle spasms, as reported in the Journal of Neurology, Neurosurgery and Psychiatry 4

Anxiety-related chest pain often presents as squeezing or tightness in the chest, which may be described as pressure, according to the American College of Cardiology and Circulation 1, 3
Pain that may last minutes to hours is a characteristic of anxiety-related chest pain, as noted in the European Heart Journal and Circulation 3, 5
Symptoms that worsen with stress are also typical of anxiety-related chest pain, as described in the European Heart Journal and Circulation 3, 5
Accompanied by other anxiety symptoms, such as shortness of breath, palpitations, and sweating, anxiety-related chest pain can be distinguished from cardiac chest pain, according to the American College of Cardiology 6

Management Approaches

The American College of Cardiology recommends referral to a cognitive-behavioral therapist for patients with recurrent, similar presentations of chest pain with negative cardiac workups, with a Class 2a recommendation 1, 3
Cognitive-behavioral therapy has shown a 32% reduction in chest pain frequency in patients with non-cardiac chest pain, as reported in the American College of Cardiology and Circulation 1, 3
Sensory grounding techniques, such as environmental awareness exercises, cognitive distractions, breathing techniques, and progressive muscle relaxation, can help manage acute anxiety symptoms, according to the Journal of Neurology, Neurosurgery and Psychiatry 4

Premature attribution of chest pain to anxiety may lead to missed diagnoses of serious conditions, especially in younger patients, as cautioned by Praxis Medical Insights 7
Anxiety should only be considered as a cause of chest pain after appropriate cardiac testing has been completed and is negative, as emphasized by Praxis Medical Insights 7
Patients with anxiety-related chest pain often undergo extensive and repetitive cardiac testing with low referral rates to mental health services, as noted by the American College of Cardiology and Circulation 1, 3

New-onset chest pain should always be evaluated medically before attributing to anxiety, as recommended by the American College of Cardiology and Praxis Medical Insights 1, 7
Patients with known anxiety disorders should still receive appropriate cardiac evaluation when presenting with chest pain, as advised by Praxis Medical Insights 7

The American College of Cardiology and European Heart Journal recommend always beginning with cardiac evaluation to rule out acute coronary syndrome (ACS), as chest pain with anxiety symptoms could still represent a cardiac emergency 8, 9
A 12-lead ECG should be obtained immediately, as its sensitivity to identify ischemia may be as low as 50%, and 2-4% of patients with evolving myocardial infarction may have normal ECG findings 10
Vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, should be assessed, as recommended by Circulation 11
The European Heart Journal suggests evaluating for associated symptoms that suggest cardiac etiology: diaphoresis, pallor, cool skin, nausea, vomiting, and dyspnea 10
Cardiac biomarkers (troponin) should be considered to help rule out myocardial infarction, according to the European Heart Journal 12

Cardiac chest pain typically presents as diffuse pain over the anterior chest wall rather than localized, and may radiate to arms, neck, and back, as described by the European Heart Journal 9
The European Heart Journal notes that cardiac chest pain is often accompanied by autonomic symptoms (diaphoresis, pallor) 10

The American College of Cardiology recommends administering oxygen if dyspnea, hypoxemia, or signs of heart failure are present, and considering ECG, cardiac biomarkers, and appropriate cardiac workup first 8, 10
If acute cardiac conditions are ruled out, the European Heart Journal suggests providing reassurance about negative cardiac findings, and considering non-invasive cardiac testing (stress testing, echocardiography) for patients with intermediate risk 8, 9, 11
For confirmed anxiety-related chest pain, the American College of Cardiology strongly recommends referral to cognitive-behavioral therapy (Class 2a recommendation) 8

The European Heart Journal notes 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 9
The American College of Cardiology recommends referring patients with non-cardiac chest pain to mental health services 8
Cognitive-behavioral therapy has shown a 32% reduction in chest pain frequency for patients with recurrent, similar presentations and negative cardiac workups, according to the American College of Cardiology 8