92.Classification of non-cardiogenic chest pain.
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Classification of Non-Cardiogenic Chest Pain
Non-cardiogenic (non-cardiac) chest pain encompasses all causes of chest discomfort not attributable to myocardial ischemia or primary cardiac pathology. The ESC guidelines recommend classifying chest pain as cardiac, possibly cardiac, or likely non-cardiac — and advise against using the term "atypical" (Management of Acute Coronary Syndromes, p. 16).
Major Categories
1. Pulmonary / Cardiopulmonary Causes
| Condition | Key Features |
|---|---|
| Pulmonary embolism | Pleuritic, sudden onset, dyspnea, risk factors (DVT, immobility) |
| Pneumothorax | Sharp, unilateral, sudden; reduced breath sounds |
| Pleuritis / Pleurisy | Sharp, worsens with breathing/movement |
| Pneumonia / Pleuropneumonia | Fever, productive cough, pleuritic component |
| Pulmonary hypertension | Exertional chest pressure, dyspnea |
| Tracheobronchitis | Burning, substernal, associated with cough |
2. Gastrointestinal Causes (most common non-traumatic cause)
(Harrison's Principles, p. 534)
| Condition | Key Features |
|---|---|
| Gastroesophageal reflux disease (GERD) | Burning, retrosternal, postprandial, relieved by antacids |
| Esophageal spasm | Intense squeezing, retrosternal; may mimic angina; relieved by nitrates or CCBs |
| Esophageal rupture (Boerhaave's) | Severe tearing pain after vomiting; mediastinitis |
| Mallory-Weiss tear | After retching; hematemesis may follow |
| Peptic ulcer disease | Epigastric pain, relation to food |
| Hiatal hernia | Postprandial, positional |
| Achalasia / motility disorders | Dysphagia + chest pain |
Esophageal spasm is particularly important — it can simulate angina in both character and location, and may even respond to nitroglycerin (Harrison's, p. 534).
3. Aortic / Vascular Causes
| Condition | Key Features |
|---|---|
| Aortic dissection | Tearing/ripping, radiates to back, maximal at onset; BP differential |
| Aortic aneurysm | Dull, deep back/chest pain |
4. Musculoskeletal Causes
| Condition | Key Features |
|---|---|
| Costochondritis (Tietze syndrome) | Reproducible with palpation of costal cartilage |
| Rib fracture / stress fracture | Trauma history, point tenderness |
| Intercostal muscle strain | Relation to exertion/movement |
| Fibromyalgia | Diffuse pain, multiple tender points |
| Cervical / thoracic radiculopathy | Dermatomal distribution, radiation to arm |
5. Skin / Neurological Causes
| Condition | Key Features |
|---|---|
| Herpes zoster (shingles) | Dermatomal burning/burning before rash appears; vesicular rash |
| Thoracic outlet syndrome | Positional, arm/shoulder involvement |
6. Psychiatric / Functional Causes
| Condition | Key Features |
|---|---|
| Panic disorder / anxiety | Palpitations, dyspnea, dizziness, situational triggers |
| Depression | Atypical diffuse chest heaviness |
| Somatoform / functional chest pain | Diagnosis of exclusion; chronic, often unresponsive to treatment |
7. Other / Miscellaneous
| Condition | Key Features |
|---|---|
| Mediastinitis | Fever, post-procedural/post-surgical |
| Pericarditis | Sharp, positional (worse supine, better leaning forward); friction rub |
| Myocarditis | Young patients, viral prodrome; technically borderline cardiac |
Summary Framework
Non-Cardiogenic Chest Pain
├── Pulmonary (PE, pneumothorax, pleuritis, pneumonia)
├── Gastrointestinal (GERD, esophageal spasm, PUD, Boerhaave's)
├── Aortic/Vascular (dissection, aneurysm)
├── Musculoskeletal (costochondritis, radiculopathy, strain)
├── Neurological/Dermatological (herpes zoster, radiculopathy)
├── Psychiatric/Functional (panic disorder, somatoform)
└── Other (pericarditis, mediastinitis)
Key Clinical Pearl: Gastrointestinal disorders — especially esophageal — are the most common cause of non-traumatic, non-cardiogenic chest pain and are the leading diagnostic pitfall because they can closely mimic ischemic chest pain (Harrison's, p. 534). Always rule out life-threatening causes (PE, aortic dissection, tension pneumothorax) before attributing chest pain to benign etiologies.
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