Chest pain is one of the most frequent presenting symptoms in medical settings. Each year 5.5 million people present to medical settings with chest pain. Fortunately for 80–90 percent of these patients, their chest pain is not due to heart disease and the vast majority of them are diagnosed with non–cardiac chest pain (NCCP).
NCCP is a term used to describe chest pain that resembles heart pain (also called angina) in patients who do not have heart disease. Noncardiac chest pain typically is felt behind the breast bone (sternum) and is described as oppressive, squeezing or pressure-like. It may radiate to the neck, left arm or the back (the spine). It may be precipitated by food intake. It lasts variable periods of time but it is not unusual for it to last hours.
Patients may also complain of associated reflux symptoms such as heartburn (a burning feeling behind the breast bone) or fluid regurgitation (a sensation of stomach juices coming back toward the chest and even to the mouth, frequently with a bitter or sour taste).
Because the pain often feels the same as heart pain or angina, patients, and their physicians, frequently attribute this pain to the heart and believe they have a life–threatening condition like a heart attack. In fact, many patients present to emergency rooms concerned about a heart attack and commonly undergo cardiac studies (such as EKGs, laboratory tests, stress tests, and even coronary angiography where dye is injected into the heart vessels). After these cardiac tests fail to show evidence of heart disease, the patients receive the diagnosis of NCCP, leading the physician to examine other causes for the chest pain.
The heart and the esophagus are located close to one another in the chest cavity (thorax). They receive a similar nerve supply. Thus, pain arising from either organ travels through the same nerve sensory fibers to the brain, where pain signals are registered and perceived. As a result, pain from either organ can feel similar, making it difficult to differentiate cardiac pain from esophageal (swallowing pipe) pain. It also indicates that a very common source of (non–cardiac) chest pain arises from the esophagus.
The most common cause of noncardiac chest pain arises from a nearby organ, the esophagus (the tube that carries food from the mouth to the stomach). Esophageal causes of noncardiac chest pain include gastroesophageal reflux disease (GERD, or acid reflux) and other abnormalities of smooth muscles of the esophagus. GERD results from stomach acid backing up into the esophagus, which produces heartburn and chest pain.
Patients with NCCP may also have a highly reactive esophagus where even the smallest change in pressure or exposure to acid triggers pain. This common condition, called visceral hypersensitivity, can best be explained by describing an experiment: when a small balloon is placed inside the esophagus and expanded, it triggers a pain response in patients with NCCP, even when the balloon is expanded at very low volumes. This differs from the reaction of control subjects without hypersensitivity who either do not report pain at very low volumes or may only report pain when the balloon is greatly expanded. Although the exact cause of visceral sensitivity is unknown, it is believed the nerve endings in the chest are quite sensitive and cause a very real perception of pain when nerve signals reach the brain and are processed along with one’s emotions, thoughts, beliefs, and prior life experiences.
Another common cause of noncardiac chest pain is musculoskeletal problems located anywhere on the chest wall. The chest contains many muscles, bones, tendons, and cartilage (the rubbery tissue that connects muscles and bones). Strains or sprains to any of these areas can cause chest pains. Chest pains associated with musculoskeletal injury are typically sharp and confined to a specific area of the chest. They may be brought on by movement of the chest and/or arms into certain positions, and often are relieved by changing position. These pains can be triggered by pushing on part of the chest and often become worse when taking a deep breath. These pains usually last only seconds, but can persist for days.
While stress does not cause NCCP, it can intensify chest pain. The chest pain often triggers the body's normal “alarm system” that functions as a survival mechanism reserved for dealing with physical dangers. This alarm reaction can lead to shortness of breath, hyperventilation, heart palpitations, sweating, and panicky feelings. When unpleasant physical sensations come out of the blue, they can trigger scary thoughts such as “I am having a heart attack”. This vicious cycle of unpleasant physical sensations and worried thoughts can crank up the volume on pain.
Noncardiac chest pain may resemble cardiac pain; therefore, you need to see a physician to rule out a more serious, life–threatening condition like heart disease. This may require further testing such as an EKG, exercise stress test, cardiac ultrasound or cardiac angiogram. If your doctor believes that the chest pain may originate from the digestive tract, you may undergo a number of GI tests. These tests may include endoscopy (to visualize and examine the esophagus for injury from acid), manometry (to identify abnormal esophageal contractions), and pH testing (to identify excessive acid reflux into the esophagus).
Most patients can achieve complete relief of their symptoms once the appropriate cause of noncardiac chest pain is identified.
If the cause of NCCP is due to a gastrointestinal problem, treatment may include:
If the cause of NCCP is a musculoskeletal problem, treatment may include:
If chest pain is not due to coronary blockage or gastrointestinal disorders, behavioral treatments may provide relief from some of the most bothersome aspects of NCCP. Behavioral treatments help the patient modify or eliminate thought patterns contributing to noncardiac chest pain and correct behaviors that keep the pain–fear cycle going. Researchers at the University at Albany found that NCCP patients who learned symptom self–management skills were able to reduce the frequency of chest pain episodes and fear of cardiac symptoms. Patients maintained these gains three months after treatment ended.
If you or someone you know is suffering from pain that medications or other therapies are not effectively controlling, the Behavioral Medicine Clinic may be able to help. Contact us online or call us at 716-898-5671 to get the help you need.
Esler, J. L., D. H. Barlow, et al. (2003). A brief cognitive-behavioral intervention for patients with noncardiac chest pain. Behavior Therapy, 34(2), 129–148.