Non-Cardiac Causes of Chest Pain

Major Categories of Non-Cardiac Chest Pain

• The American College of Cardiology notes that musculoskeletal causes are the most common non-cardiac causes of chest pain, with costochondritis being characterized by pain reproducible with palpation of the costochondral junctions 1, 2
• The American College of Cardiology recommends considering cervical radiculopathy as a cause of non-cardiac chest pain, characterized by pain radiating from the cervical spine 3
• Gastroesophageal reflux disease (GERD) is the most common esophageal cause of non-cardiac chest pain, according to the American Heart Association 1
• Peptic ulcer disease may present with epigastric pain radiating to the chest, as noted by the American College of Cardiology 1, 3
• Pulmonary embolism (PE) is characterized by tachycardia, dyspnea, and pain with inspiration in >90% of patients, according to the American Heart Association 1, 4
• The American College of Cardiology states that pneumonia may cause localized pleuritic chest pain with friction rub 1, 4
• Pneumothorax is characterized by pleuritic chest pain with unilateral decreased or absent breath sounds, as noted by the American Thoracic Society 1, 4
• Pleuritis is characterized by sharp pain that worsens with deep breathing, according to the American College of Chest Physicians 3
• Anxiety disorders and panic attacks are often associated with other somatic symptoms, as noted by the American Psychiatric Association 1, 3
• Somatoform disorders are physical symptoms without identifiable organic cause, according to the American Psychiatric Association 3
• Herpes zoster is a painful rash in a dermatomal distribution, as noted by the American Academy of Dermatology 1, 4
• Sickle cell crisis may present with acute chest syndrome, according to the American Society of Hematology 5
• Aortic dissection is characterized by sudden onset of severe chest or back pain with pulse differential (30% of patients), as noted by the American Heart Association 4

Diagnostic Approach

• The American College of Cardiology recommends evaluating for life-threatening causes (aortic dissection, PE, esophageal rupture) in the initial assessment of non-cardiac chest pain 1, 4
• Focused cardiovascular examination to identify complications is recommended by the American Heart Association 4
• The American College of Gastroenterology recommends considering upper endoscopy when an esophageal cause is suspected 1
• Trial of empiric acid suppression therapy for suspected GERD is recommended by the American Gastroenterological Association 1
• The American College of Cardiology recommends considering esophageal function testing and pH monitoring if symptoms persist despite treatment 1
• Cognitive-behavioral therapy has shown a 32% reduction in chest pain frequency, according to the American Psychological Association 5

Management Strategies

• The American College of Cardiology recommends addressing psychological comorbidities in all patients with non-cardiac chest pain 5

Special Considerations

• Patients with sickle cell disease reporting acute chest pain require emergency transfer to acute care settings to exclude acute chest syndrome, as noted by the American Society of Hematology 5
• Valvular heart disease can present with chest pain that may be confused with non-cardiac causes, particularly in stenotic valvular disease, according to the American College of Cardiology 2
• For patients with multiple similar presentations and negative cardiac workups, psychological factors should be addressed, as these are often overlooked in clinical practice, as noted by the American Psychiatric Association 5

Pitfalls to Avoid

• Assuming all non-cardiac chest pain is benign - some causes like PE and aortic dissection are life-threatening, according to the American Heart Association 1, 4
• Failing to consider psychological factors - these are common but frequently overlooked, as noted by the American Psychiatric Association 5
• Overlooking medication-related causes - NSAIDs, potassium supplements, iron, and bisphosphonates can cause esophageal irritation, according to the American Gastroenterological Association 1