Noncardiac Chest Pain

Noncardiac chest pain (NCCP) is frequent, recurring pain in your chest that’s not related to your heart. It feels and behaves like cardiac chest pain (angina), but it isn’t. Healthcare providers diagnose noncardiac chest pain after ruling out heart-related causes. It’s often related to your esophagus (food pipe) instead.

Inside your chest cavity, your esophagus runs right alongside your heart. The same sensory nerves send pain signals from both organs to your brain. So, it may be hard to tell exactly where the sensations are coming from. It’s no coincidence that what we call “heartburn” is actually acid reflux in your esophagus.

Most people who experience chest pain don’t have heart disease. But it can be hard to tell if your chest pain is from heartburn or a heart attack, or something else. That’s why it’s important to seek care for chest pain. A qualified healthcare provider can determine if you have cardiac or noncardiac chest pain.

Symptoms of noncardiac chest pain

Noncardiac chest pain resembles cardiac chest pain (angina). It might feel like:

• Pressure or a heavy weight in your chest
• Tightness, clenching or squeezing
• Intense stress, panic or dread
• Heartburn or indigestion
• It’s located behind your breastbone
• It spreads to your neck, back or arms

Like cardiac chest pain, noncardiac chest pain may start after a stressful event or after a large meal. It may last from a few seconds to a few hours. If it lasts longer than a few minutes, you should seek care.

Unlike cardiac chest pain, noncardiac chest pain is unlikely to:

• Cause sweating or shortness of breath
• Feel better when you take nitroglycerin

Causes of noncardiac chest pain

GERD (chronic acid reflux) is the most common cause of noncardiac chest pain, and of chest pain in general. When gastric acid escapes from your stomach and backwashes into your esophagus, it burns it on the inside, causing pain. You feel it in your chest because your esophagus runs through your chest.

Other possible causes include:

• Esophagitis: GERD is a common cause of inflammation in your esophagus (esophagitis), but not the only cause. Infections, medications and eosinophilic esophagitis are a few others.
• Esophageal muscle problems: Motility disorders affect the muscles in your esophagus. They can cause esophageal muscle spasms or constrictions, which can cause pain and swallowing issues.
• Hypersensitivity: If the nerves in your esophagus are hypersensitive, they might feel discomfort even with very small changes in pressure or acid. This is also called “functional chest pain.”
• Chest wall pain: Musculoskeletal chest pain usually feels different from cardiac chest pain. But some inflammatory conditions might feel similar, like costochondritis or slipping rib syndrome. If pain increases when you apply pressure to the spot, it might be musculoskeletal pain.
• Psychological conditions: Panic, anxiety and depression can manifest as chest pain. Feelings can also make physical pain worse. This is common in people with hypersensitivity disorders.
• Digestive difficulties: Gas and bloating in your stomach that doesn’t flow downward into your intestines may flow upward and escape into your esophagus instead. This can cause chest pain.
• Lung conditions: Chronic pain could be from fluid around your lungs (pleural effusion or pleurisy). Or it could be trapped air around your lungs (pneumomediastinum or pneumothorax).

Risk factors

You may be more likely to experience noncardiac chest pain if you:

• Have a psychological disorder (these affect most people with NCCP)
• Have another functional pain disorder, like functional dyspepsia or IBS
• Have significant life stress and/or sleep problems
• Use alcohol or tobacco regularly

How doctors diagnose noncardiac chest pain

Doctors diagnose noncardiac chest pain after ruling out cardiac causes. If you experience symptoms that resemble cardiac chest pain, you should go to the emergency room. A healthcare provider will review your symptoms, take your vital signs and screen you for a heart attack or heart disease.

Common screening tests include:

• Blood tests
• Electrocardiogram
• Exercise stress test
• Heart CT scan

After ruling out cardiac conditions, they’ll diagnose noncardiac chest pain. They might refer you to a gastroenterologist next. Gastroenterologists can diagnose and treat conditions related to your esophagus. They can screen you for GERD and other esophageal disorders, as well as digestive diseases.

These tests might include:

• Esophageal manometry
• Esophageal pH test
• Upper endoscopy
• Ultrasound

Sometimes, a healthcare provider might try treating you with medications for GERD before testing for it. This is just a different way of screening you for GERD. If proton pump inhibitors (PPIs) relieve your chest pain, your provider can confidently diagnose GERD chest pain. If not, they can proceed with further tests.

How is noncardiac chest pain treated?

Treatment for noncardiac chest pain depends on the causes. Common treatments include:

• Acid reflux medications: Proton pump inhibitors are the most common and most effective medications for GERD. They can also help soothe inflammation (esophagitis) from other causes.
• Esophageal motility treatments: You might need these treatments if you have muscle spasms or constriction in your esophagus. They include medications and procedures to relax it or stretch it.
• Pain modulators: Low doses of some antidepressants can treat chronic pain, as well as psychological conditions. Tricyclic antidepressants and selective serotonin reuptake inhibitors are two.
• Psychological therapies: Psychological therapy takes many forms. It includes traditional “talk” psychotherapy, mind-body therapies like biofeedback and stress management techniques.

What can I expect if I have noncardiac chest pain?

Treating noncardiac chest pain may be simple or complex, depending on the cause. Most people respond to proton pump inhibitors or antidepressant pain modulators. If you have a more complex condition, you might need more extensive treatment, or a combination of different approaches.