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The head says yes but the heart says no: what is non-cardiac chest pain and how is it managed?
  1. J B Chambers1,
  2. E M Marks1,2,
  3. M S Hunter2
  1. 1Cardiothoracic Centre, Guy's and St Thomas Hospital, London, UK
  2. 2Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
  1. Correspondence to Professor John Chambers, Cardiology Administration, Cardiothoracic Centre, Guy's and St. Thomas’ Hospital, F06, East Wing, London SE1 7EH, UK; John.Chambers{at}gstt.nhs.uk

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Learning objectives

  • To recognise the causes and natural history of non-cardiac chest pain.

  • To recognise features in the history and examination which differentiate cardiac pain from non-cardiac chest pain.

  • To explore and treat the psychological factors initiating and maintaining non-cardiac chest pain.

CURRICULUM TOPIC: Chronic ischaemic heart disease

Introduction

Chest pain is common and usually non-cardiac in origin. The lifetime population prevalence of non-cardiac chest pain (NCCP) is approximately 20–33%1–7 compared with approximately 6–7% for angina.3 ,8 The incidence of NCCP depends on the clinical setting. It is 70–80% for patients presenting to a general practitioner or a rapid access chest pain clinic9–11 and around 50% attending emergency departments.12 ,13 Normal coronary anatomy is found in 40% having diagnostic coronary angiography.14

Despite this, the focus of clinical care is on excluding coronary disease rather than on the positive management of NCCP. As a result, patients with NCCP are often left with chronic symptoms, high levels of psychological distress,15 ,16 high unemployment and heavy use of healthcare resources.17–19 The causation may be complex with an interaction of organic and psychological processes. However, treatment can be effectively delivered at low cost.20 ,21

This article describes the causes, natural history and management of NCCP with an emphasis on the psychological processes which inform our approach to care.

What is NCCP?

Chest pain may be obviously benign, for example after straining a muscle or being hit in the chest by a football. It only becomes of medical concern when the person seeks advice for one or more reasons: severe or recurrent pain; a family history of coronary disease; health anxiety as a result of personality or induced by societal concerns, for example, healthcare advertisements. The general practitioner may be confident to reassure the person without tests. However, someone referred to a cardiac outpatient or …

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