Atypical chest pain: looking beyond the heart.

Chest pain is common, and tends to be overinvestigated. Patients with normal coronary anatomy have a low mortality, but remain significantly incapacitated. We discuss ways of improving the management of such patients. An early diagnosis of a non-cardiac cause of pain should be made, ideally by the general practitioner, taking account of risk factors for cardiac as well as psychological disorders, the quality of the pain, the patient's concerns and worries and the presence of stressful life events. The minimum of investigation should be performed. Cardiological referral should be considered for patients with a high a priori risk of ischaemic heart disease. Otherwise referral, if necessary, should be to a gastroenterologist, psychiatrist or clinical psychologist, as appropriate. Treatment options are medications with musculoskeletal or oesophageal activity, simple or repeated reassurance, cognitive therapy, psychiatric drugs, and respiratory retraining. We suggest that a multidisciplinary chest-pain clinic may improve the care of such patients.