Approach to the patient with unexplained chest pain

What are some take-home lessons on the syndrome of unexplained chest pain? Carefully exclude heart disease, which--unlike esophageally caused chest pain--may be life-threatening. Noncardiac chest pain is a common problem: at least 25% of chest pain patients in coronary care units or emergency rooms "rule out" for heart disease. It is a problem that has been vexing physicians for at least 100 years. The pain patterns in ischemic heart disease and in the unexplained pain syndromes, particularly reflux, may be identical. The mechanism may be an "irritable" esophagus, in which the visceral pain threshold is lowered. Look carefully for gastroesophageal reflux, and treat it aggressively. Finally, in all cases, try to establish a diagnosis if at all possible. When patients are told they don't have heart disease and no further workup is pursued, more than half of them continue to have significant morbidity from their chest pain, utilizing health care facilities and visiting doctors (34,35). Research over the past two decades has enlightened us about many patients with unexplained chest pain, but unfortunately we are still confused about many others, and for this group of patients a conservative therapeutic approach may be best.