The head says yes but the heart says no: what is non-cardiac chest pain and how is it managed?

Chest pain is common and usually non-cardiac in origin. The lifetime population prevalence of non-cardiac chest pain (NCCP) is approximately 20–33%1–7 compared with approximately 6–7% for angina.3 ,8 The incidence of NCCP depends on the clinical setting. It is 70–80% for patients presenting to a general practitioner or a rapid access chest pain clinic9–11 and around 50% attending emergency departments.12 ,13 Normal coronary anatomy is found in 40% having diagnostic coronary angiography.14

Despite this, the focus of clinical care is on excluding coronary disease rather than on the positive management of NCCP. As a result, patients with NCCP are often left with chronic symptoms, high levels of psychological distress,15 ,16 high unemployment and heavy use of healthcare resources.17–19 The causation may be complex with an interaction of organic and psychological processes. However, treatment can be effectively delivered at low cost.20 ,21

This article describes the causes, natural history and management of NCCP with an emphasis on the psychological processes which inform our approach to care.