NON-CARDIAC CHEST PAIN

Noncardiac chest pain is defined as recurring pain in your chest — typically, behind your breast bone and near your heart — that is not related to your heart. In most people, noncardiac chest pain is actually related to a problem with their esophagus, most often gastroesophageal reflux disease (GERD). Stress, anxiety and depression can also manifest as chronic chest pain. Other conditions can cause short-term, acute chest pain, including lung problems and musculoskeletal injuries. But noncardiac chest pain (NCCP) is diagnosed as a chronic condition.

What does noncardiac chest pain feel like?

Noncardiac chest pain is often described as feeling like angina, the chest pain caused by heart disease. It feels like a painful squeezing or tightness in your chest, or like pressure or heaviness, particularly behind your sternum. You may feel it on the right side or the left side or in the middle. Sometimes the pain radiates to your neck, left arm or back. You may notice that it occurs after eating, or that it is accompanied by heartburn, a burning sensation in the chest. It can last for a few minutes or a few hours.

Why does pain in the esophagus feel like heart pain?

Inside your chest cavity (thorax), your esophagus actually runs right alongside the heart. The same sensory nerves send pain signals from both organs to your brain. It can be difficult to distinguish between the two based on symptoms alone. If you have other symptoms of esophageal reflux, such as stomach fluid coming back up through your esophagus, that can be a clue. Other esophageal disorders, such as muscle spasms or visceral hypersensitivity, might be trickier to identify.

How common is noncardiac chest pain?

Noncardiac chest pain affects up to 25% of adults in the UK. Between 50% and 75% of chest pain cases presenting to emergency rooms are discharged without a cardiac diagnosis. These cases are classified either as unexplained, as stress- or anxiety-induced or as NCCP.

How do I know if my chest pain is serious?

You may not be able to tell the difference between a heart attack and noncardiac chest pain. For this reason, you should always take chest pain seriously. If it is sudden or new and lasts longer than five minutes, go to the emergency room. If it goes away after a few minutes, it may not be an emergency, but you should still see your healthcare provider as soon as possible to determine the cause. Noncardiac chest pain, whatever the cause, can always occur again, and can end up affecting your quality of life.

What are the most common causes of noncardiac chest pain?

Noncardiac chest pain is most commonly related to a problem with your esophagus, the “swallowing tube” that connects your mouth to your stomach. There are several different esophageal disorders that can cause noncardiac chest pain, including:

  • Gastroesophageal reflux disease (GERD). Otherwise known as chronic acid reflux, this is the most common cause of noncardiac chest pain, accounting for 50% to 60% of cases.
  • Esophageal muscle spasms. Abnormal contractions or squeezing of your esophagus.
  • Achalasia. This is a rare disorder in which your lower esophageal sphincter doesn’t relax and open to allow food into your stomach, causing food to back up into your esophagus.
  • Esophageal hypersensitivity. This is a sensory disorder in which the muscles, nerves and receptors of your esophageal wall are overly sensitive. People with this condition experience normal tension, pressure changes, and acid contents as painful.
  • Inflammation of the esophagus. This can result from an immune response to infection or food allergies (eosinophilic esophagitis,) or from peptic ulcer disease.
  • Abnormal esophageal tissue. This creates constrictions, such as rings and webs.

When healthcare providers can’t determine the cause but have ruled out other possible factors, they diagnose “functional chest pain of presumed esophageal origin.”

What other problems can cause noncardiac chest pain?

Some less common causes of noncardiac chest pain include:

  • Muscle or bone problems in the chest, chest wall, or spine (back).
  • Chronic lung diseases, including diseases of the pleura, the tissue that covers your lungs.
  • Stomach problems, such as ulcers.
  • Psychological problems, including pain disorders, stress, anxiety and depression.

Do people with noncardiac chest pain have other symptoms?

People with noncardiac chest pain commonly have other symptoms of GERD, including heartburn and acid reflux. They also report a higher incidence of other gastrointestinal (GI) complaints, including sore throat, regurgitation and difficulty swallowing. Up to 80% of those with functional noncardiac chest pain report other functional GI disorders with no obvious explanation, especially IBS (27%) and functional abdominal bloating (22%).

For some people, noncardiac chest pain is associated with psychological symptoms, such as stress, anxiety and depression. This is true even when the cause is determined to be something else. In fact, there is a significant crossover between psychological symptoms and symptoms of esophageal hypersensitivity, as well as heartburn. Psychological stress can trigger gastrointestinal symptoms, and vice versa. Doctors have speculated that this is due to a disorder of the gut-brain connection.

What risk factors are associated with noncardiac chest pain?

Correlation, but not causation, has been shown between noncardiac chest pain and:

  • High BMI.
  • Smoking or tobacco use.
  • NSAIDs.
  • Anxiety.

How is noncardiac chest pain diagnosed?

If you experience chest pain that resembles cardiac chest pain, you should go to the emergency room. On arrival, you’ll receive a complete physical exam that measures all of your vital signs, including blood pressure and heart rate. Then you’ll be screened for heart attack or heart disease. Tests include an electrocardiogram (EKG) — a noninvasive test that records your heart’s electrical activity — and blood tests. Your heart releases certain proteins when a heart attack occurs that will show up in a blood test. Only when cardiac factors have been ruled out will you be diagnosed with noncardiac chest pain.

Once a cardiologist or your primary care provider has ruled out cardiac causes, you’ll likely be referred to a gastroenterologist next. They’ll test you for esophagus-based causes, starting with GERD. One way of testing is to send you home with a proton-pump inhibitor (PPI), a highly effective medicine for GERD. If the PPI relieves your symptoms, it can also confirm their cause. Other tests may include a PH study of the esophagus, an esophageal motility test, an upper endoscopy or ultrasound. In addition to physical tests, your healthcare provider will take a medical history and ask about your stress and emotional factors.

How is noncardiac chest pain treated?

Effective treatment depends on identifying the cause of your noncardiac chest pain. Some options include:

Acid reflux treatments

If your noncardiac chest pain is, like most people’s, from GERD, treatment is usually simple and effective. Proton-pump inhibitors (PPI) are the most commonly used medicine to treat GERD. PPIs reduce the amount of stomach acid that your glands secrete, which also allows ulcers and acidic corrosion to heal. Treatment usually begins with a high dosage to control your symptoms, then continues with a low dosage for two to four months. PPIs are about 90% effective in treating GERD and its side effects. If they are ineffective, it probably means that your NCCP is caused by something else.

Pain blockers

The next most common and effective treatment for noncardiac chest pain is a medicine that blocks the pain signals. These are usually from a class of drugs known as tricyclic antidepressants (TCAs), used in much lower dosages than they are used to treat depression. If side effects prevent you from tolerating TCAs, other categories of antidepressants might work. Selective serotonin reuptake inhibitors (SSRI) have shown some promise in treating NCCP, although they are less well-established than TCAs.

Emotional and behavioral therapies

Noncardiac chest pain can be related to depression, anxiety or stress. Psychotherapy can help you to work through these problems to reduce the occurrence of chest pain. Cognitive behavioral therapy can teach you how to change or eliminate the thought patterns that trigger stress or anxiety. Biofeedback is a guided mind-body therapy that can help you change the way your body responds to certain stimuli, including thoughts. You can also try stress management techniques at home, such as meditation, exercise and relaxation.

Noncardiac chest pain can be scary, especially when it feels like cardiac chest pain. Recurring episodes can be frustrating and interfere with your quality of life. Always take chest pain seriously. Finding the cause of your chest pain might take some investigation, but it’s worthwhile. Most causes, when they are identified, are simple to treat. When they are complex, there is a lot to be learned about how your body responds to foods, stress and thoughts that can put you on the path to long-term recovery.

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