Diagnosis and Management of Noncardiac Chest Pain

Abstract

Noncardiac chest pain is a challenging condition often encountered by primary care providers, emergency medicine physicians, and gastroenterologists. It is frequently accompanied by persistent symptoms, diagnostic uncertainty, decreased quality of life, and high health care burden. Gastroesophageal reflux disease is the most common esophageal cause followed by functional chest pain, and at least half of patients with noncardiac chest pain have psychiatric comorbidities such as anxiety or depression. Management is focused on identification of an underlying cause to target treatment and address psychiatric comorbidities. This article discusses the evaluation and management of the common gastrointestinal causes of noncardiac chest pain.

Keywords: Noncardiac chest pain; distal esophageal spasm; esophageal motility disorders; functional chest pain; gastroesophageal reflux disease; hypercontractile esophagus.

Figure.

Flow algorithm depicting the evaluation of patients with NCCP., ^aIn patients undergoing EGD without diagnostic findings of GERD (ie, erosive esophagitis or Barrett esophagus), ambulatory pH monitoring with wireless telemetry capsule can be considered at the time of EGD. ^bAmbulatory pH monitoring is generally performed after stopping PPI therapy for at least 1 to 2 weeks to evaluate for GERD. ^cIn patients with GERD, management may include lifestyle changes, increasing the dose and/or frequency of PPI therapy, or switching to a more potent PPI. Select patients may be considered for referral for antireflux surgery. EGD, esophagogastroduodenoscopy; GERD, gastroesophageal reflux disease; NCCP, noncardiac chest pain; PPI, proton pump inhibitor.