The patient with non-cardiac chest pain

Backgroundnon-cardiac chest pain (NCCP) is recurrent retrosternal chest pain in the absence of significant coronary artery disease. It can affect up to 25% of the population.Pathophysiologygood history and examination help to differentiate between causes of chest pain, such as coronary heart disease, musculoskeletal pain, abdominal disease, pulmonary causes and oesophageal pathology. Targeted investigations should be performed according to clinical suspicion.Patients with a high risk of ischaemic heart disease should have cardiac investigations. Those likely to have NCCP should, if possible, be identified early, to prevent the all-too-common scenario of patients continuing for years to present to primary and secondary healthcare professionals and remaining limited in their ability to perform physical activities or to work. Gastro-oesophageal reflux disease is a common cause of NCCP, occurring in up to 50% of patients. If there are any red flag signs, a gastroscopy should be performed to rule out upper gastro-intestinal pathology. Oesophageal dysmotility, including achalasia and diffuse oesophageal spasm, are rare causes, while visceral hypersensitivity is common. A proportion of patients have psychiatric disease in isolation or combination with the above.Managementin primary care, an empirical trial of a four-week course of twice-daily proton pump inhibitor (PPI) is a useful diagnostic and therapeutic test. In case of response, maintenance dose PPI should be continued. Referral to a gastroenterologist should be considered if there is no response. 24-hour oesophageal pH monitoring can identify patients with reflux unresponsive to PPI; oesophageal dysmotility can be identified by manometry in selected patients. Tricyclic antidepressants at relatively low dose may have a role. Behavioural therapy and hypnotherapy have been found to be useful in selected cases.Summarychest pain should be taken seriously, with any underlying pathology identified and treated early. Patients with NCCP should receive repeated and consistent reassurance, in the hope of averting chronic disability. A multidisciplinary approach to NCCP may be required in those with chronic symptoms.