Unexplained Chest Pain: A Cost-Effective Approach

Once you have excluded a cardioc origin of chest pain, focus the evaluation an esophaged, psychiatric, musculoskeletal, and pulmoncry causes. Gastroesophaged reflux disease (GERD) and esophaged motility disorders are the most common couses of unexplained chest pain (UCP). If you suspect an esophaged disorder, empiric antisecretory therapy is the most cost-effctive initial approch. If the patient remains symptomatic, order a 24-hour esophaged pH study with symptom analysis while the patient receives maximal add suppression. Once GERD is excluded, the patient may be treated for visceral hyperalgesia with low-dose tricydic antidepressants or standard doses of selective serotonin reeptake inhibitors. Panic disorder-the most common psychiatric disorder in patients with UCP-is often associated with atypical symptoms, such as palpitations and paresthesias, and other psychiatric disorders. If you suspect panic disorder, one approach is to give the patient a short-term, nonrefillable prescription for a benzodiazepine and refer him or her for psychiatric evaluation.