Summary
Functional chest pain is characterized by recurrent chest pain or discomfort without a discernible cause. The pathophysiology of functional chest pain is unclear but includes a combination of esophageal factors (e.g., esophageal hypersensitivity) and non-esophageal factors (e.g., anxiety). The diagnosis is based on the Rome IV criteria after other causes of chest pain (especially cardiac and esophageal causes) have been excluded. Psychological comorbidities (e.g., anxiety disorders, depressive disorders) are common. Treatment includes psychotherapy (e.g., cognitive behavioral therapy) and pharmacological treatment with central neuromodulators (e.g., tricyclic antidepressants, SSRIs).
Pathophysiology
- The exact pathophysiology is unclear.
- Factors include: [1][2]
- Esophageal hypersensitivity
- Autonomic dysregulation
- Peripheral sensitization and/or central sensitization
- Hypervigilance
Clinical features
- Retrosternal chest pain or discomfort
- No associated esophageal symptoms (e.g., heartburn or dysphagia) [3]
Diagnosis
Diagnosis is confirmed based on Rome IV criteria for functional chest pain and can only be established after other causes of chest pain have been excluded. [4]
Approach [2][3]
- Rule out non-functional causes of chest pain, including:
- Immediately life-threatening causes of chest pain
- Cardiac causes, especially coronary artery disease
- Gastrointestinal causes, e.g.:
- GERD: PPI trial and/or EGD (see also “Diagnosis of GERD”)
- Eosinophilic esophagitis: EGD with biopsy
- Esophageal motility disorders (e.g., achalasia): high-resolution esophageal manometry
- Consider other causes (e.g., pulmonary causes of chest pain) depending on clinical evaluation.
- Confirm Rome IV criteria for functional chest pain are met.
Functional chest pain is a diagnosis of exclusion.
Diagnostic criteria for functional chest pain
| Rome IV diagnostic criteria for functional chest pain [1][4] | |
|---|---|
| Criteria |
|
| Requirements |
|
Differential diagnoses
- See “Chest pain.”
- Other functional esophageal disorders including: [1][4]
- Functional dyspepsia
- Reflux hypersensitivity [1]
- Globus [1]
- Functional dysphagia [1]
The differential diagnoses listed here are not exhaustive.
Treatment
General principles [1][2][3]
- Treatment is mostly supportive. [2]
- Reassure patients that functional chest pain is benign.
- Refer for psychological evaluation and treatment for comorbidities (e.g., anxiety disorders, depressive disorders).
- Consider psychotherapy (e.g., cognitive behavioral therapy). [5]
- Pharmacological treatment (e.g., central neuromodulators) may relieve symptoms.
Treatment of psychiatric comorbidities may help relieve chest pain. [3]
Pharmacological treatment [2][6]
- Central neuromodulators can be effective for managing pain. [1][2]
- Start with the lowest dose and gradually increase depending on response and adverse effects.
- Options include:
- Tricyclic antidepressants (e.g., amitriptyline)
- SARIs (e.g., trazodone)
- SSRIs (e.g., sertraline)
- SNRIs (e.g., venlafaxine)
- Gabapentinoids (e.g., gabapentin)
Psychotherapy and antidepressants are indicated in patients with or without comorbid psychiatric conditions. The therapeutic effect of central neuromodulators on hyperalgesia is independent of the effect on mood disorders. [2][7]