Issues in the treatment of noncardiac chest pain

Evaluation of therapy for noncardiac chest pain calls for a systematic analysis of all relevant factors. Central chest pain is often experienced as a threat to life. Fear and anxiety concerning heart disease or cancer can increase pain and hamper therapy. The relief of pain can result from factors other than the actual treatment employed (i.e., placebo effects, relief of anxiety, spontaneous improvement, changes in life-style not related to treatment, or other, concomitant therapies prescribed). Therapeutic failure may be explained by diagnostic error, incorrect treatment, insufficient duration of therapy, incorrect dosage regimen, individual response to pharmacologic agents, poor drug absorption, drug interactions, poor compliance, poor surgical technique, and, finally, lack of effective therapeutic options. The rational evaluation of therapy for noncardiac chest pain is also hampered by its multifactorial etiology and the difficulty of selecting study patients with identical pain etiology. Controversies in the treatment of noncardiac chest pain reflect the uncertainty regarding pathophysiology. A primary issue is whether to treat patients medically with life-style modifications and pharmacologic agents, or surgically. A variety of pharmacologic agents and surgical techniques have been used to treat noncardiac chest pain. Treatment includes psychosocial considerations in addition to medical or surgical therapy. The most important role for the physician of a patient with noncardiac chest pain is to listen well, to be confirming and understanding, and to treat the patient not just as an apparatus that needs repair but as a socially integrated human being.