Recurrent Chest Pain in Young Adult: Distinguishing Anxiety from Cardiac Etiology

Case at a Glance

A 27-year-old male presents with a 3-year history of recurrent chest pain episodes, extensively worked up with negative cardiac investigations, likely representing anxiety-related chest pain with muscular components.

Patient's Story

The patient reports experiencing chest pain for over 3 years, typically described as crushing pain in the center of his chest. Episodes usually last 1-2 weeks with constant daily pain that significantly impacts his quality of life. Three weeks prior to presentation, the pain pattern changed, extending down his left serratus anterior muscle and slightly to the left of center chest. The patient describes sudden onset episodes where he was feeling well, then experienced intense pain accompanied by overwhelming fear. He reports that certain spots are tender to palpation. The patient has a history of anxiety disorder and gastroesophageal reflux disease, currently treated with esomeprazole and sertraline. He recently initiated weekly psychotherapy sessions. No family history of cardiac disease is reported.

Initial Assessment

Multiple emergency department visits over 3 years with consistent normal findings. Patient exhibits significant anxiety surrounding chest pain episodes, describing catastrophic thinking patterns and fear of cardiac events. Physical examination notable for reproducible chest wall tenderness.

The Diagnostic Journey

Extensive cardiac workup performed over 3 years including: multiple electrocardiograms (most recent 3 weeks ago), chest X-rays, CT scan of chest (performed 2 years ago), and serial cardiac biomarkers - all within normal limits. Patient underwent repeated evaluations in emergency settings with consistent reassurance of normal cardiac function.

Final Diagnosis

Primary diagnosis: Anxiety-related chest pain with muscular component (costochondritis/chest wall pain syndrome). Secondary diagnoses include generalized anxiety disorder and gastroesophageal reflux disease.

Treatment Plan

1. Optimization of anxiety management with consideration for propranolol as needed for physical anxiety symptoms 2. Continuation of weekly psychotherapy with focus on panic attack management and catastrophic thinking patterns 3. Education on diaphragmatic breathing techniques 4. Reassurance regarding extensive negative cardiac workup 5. Follow-up with primary care physician to discuss medication adjustments, including possible SSRI optimization 6. Patient counseled to avoid repeated emergency department visits for similar symptoms unless accompanied by new concerning features

Outcome and Follow-up

Patient demonstrated improved understanding of anxiety-chest pain connection and was provided with coping strategies. Scheduled for continued psychotherapy sessions and primary care follow-up for medication management. Patient educated on appropriate use of breathing exercises and when to seek emergency care. Emphasis placed on the benign nature of his extensively investigated chest pain and the role of anxiety in symptom perpetuation.