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Non-cardiac chest pain: assessment and management
  1. J CHAMBERS, Senior Lecturer in Cardiology
  1. C BASS, Consultant in Liaison Psychiatry
  1. R MAYOU, Professor of Psychiatry
  1. Guy's and St Thomas' Hospitals
  2. Lambeth Palace Road, London SE1 7EH, UK
  3. John Radcliffe Hospital
  4. Oxford OX3 9DU, UK
  5. Warneford Hospital
  6. Oxford OX3 7JX, UK
  7. Correspondence to: Dr Chambers
  8. email:

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Chest pain is a common reason for patients to attend cardiac clinics, but the cause of pain in more than 50% of these patients is non-cardiac.1 In a recent study of 660 consecutive referrals to a “one stop” clinic, only 27% had a cardiac cause for their symptoms.2 Another group, which is particularly difficult to manage, is that with a combination of ischaemic heart disease and non-cardiac pain.3 Patients with non-cardiac pain have a good outcome in terms of mortality4 but continue to experience pain, tend to remain on cardiac medication, and continue to attend emergency departments, primary care, and outpatient clinics.4 Regrettably, both patient and doctor may find an initial, but erroneous, diagnosis of cardiac pain difficult to revoke.5


Most research has involved patients with a normal angiographic appearance to the large epicardial arteries. Although a small proportion of such patients with ST segment depression may have underlying cardiac disease,6 most have atypical pain and normal exercise tests.7 ,8 In these patients, a benign non-cardiac cause is likely. Thus about 50% of all patients with normal coronary anatomy and non-cardiac chest pain have oesophageal reflux or motility disorders,4 approximately 60% have evidence of breathing disorders,7 ,8 and 60% a psychiatric disorder.4 ,9 Psychiatric causes include panic, major depression, and health anxiety (hypochondriasis-like and other so called somatoform disorders). However, the clinical significance of oesophageal and respiratory abnormalities is not straightforward as they often do not coincide with pain.10 ,11 Furthermore, the response to specific treatment is variable4 raising the possibility that these abnormalities are coincidental rather than causative.

Half of the patients with chest pain and normal angiographic anatomy have two or more of the aforementioned conditions (oesophageal, respiratory, or psychiatric abnormalities). …

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