A practical approach to non-cardiac chest pain

Non-cardiac chest pain accounts for a substantial share of presentations to emergency departments and primary care clinics across Australia. Once myocardial ischaemia has been excluded, the clinician faces a broad differential dominated by esophageal causes. Identifying the precise source of pain is essential, because treatment varies considerably depending on whether reflux, motility or functional mechanisms are responsible.

In Australia, the typical pathway involves assessment by a general practitioner, followed by triage through a public hospital outpatient service or a private specialist. Waiting times for public endoscopy vary widely between metropolitan Sydney or Melbourne and regional centres in Queensland or Western Australia, shaping how clinicians prioritise investigations.

High-resolution manometry and ambulatory reflux monitoring have transformed the diagnostic landscape in recent years. This article outlines a structured framework, from the initial consultation through to targeted therapy, that delegates can adapt to their local practice.

Esophageal chest pain spans reflux disease, major and minor motility disorders and functional pain syndromes. Each requires a different investigative pathway and therapeutic strategy, and recognising the dominant mechanism early avoids unnecessary testing.

Confirming a non-cardiac origin

Acute coronary syndrome must be excluded using local protocols. In most Australian hospitals this means serial troponin measurement, a 12-lead electrocardiogram and risk stratification. Documenting a normal or non-diagnostic result provides the foundation for subsequent esophageal evaluation.

For patients referred late, the original cardiac workup should be reviewed. Where doubt persists, repeat stress testing or outpatient cardiology review may be appropriate before pursuing a gastrointestinal pathway.

It is helpful to clarify with the patient that "non-cardiac" does not mean "non-serious". The esophagus is a complex muscular organ capable of producing genuine pain, and framing the next steps constructively improves engagement.

Taking a targeted clinical history

A detailed history remains the most informative part of the consultation. Clinicians should explore pain quality, duration, radiation and triggers, alongside associated dysphagia, heartburn, regurgitation, weight loss and nocturnal cough.

Red flag features including new onset pain after 55, dysphagia, haematemesis, iron deficiency and persistent vomiting warrant prompt endoscopy. These align with the Gastroenterological Society of Australia referral guidance and help triage urgent gastroscopy in overstretched public lists.

Anxiety, depression and panic disorder commonly coexist with chronic chest pain and amplify symptoms. A brief screen using a validated tool identifies those who may benefit from psychological support alongside medical therapy.

Reflux-related esophageal pain

Gastroesophageal reflux disease is the leading esophageal cause of chest pain. Symptoms often mimic ischaemia, with substernal burning radiating to the back or jaw, triggered by recumbency or large meals. A therapeutic proton pump inhibitor trial, prescribed under the Pharmaceutical Benefits Scheme, is often used both diagnostically and therapeutically.

Responders without alarm features may not require further testing. Those with persistent or atypical symptoms warrant endoscopy to exclude erosive disease, Barrett's oesophagus or malignancy. Endoscopy capacity is finite in Australian public hospitals, so prioritisation by clinical urgency is essential.

Ambulatory pH or pH-impedance monitoring is reserved for unclear cases after endoscopy and an adequate PPI trial. The test is available in major centres across Sydney, Melbourne, Brisbane and Perth, though waiting lists can stretch to several months in regional networks.

Esophageal motility disorders

Achalasia, distal esophageal spasm and jackhammer esophagus produce a smaller but clinically important group of presentations, often with dysphagia to solids and liquids, regurgitation and weight loss. High-resolution manometry, interpreted using the Chicago Classification, is the diagnostic gold standard.

Access to manometry is concentrated in metropolitan teaching hospitals. Coordinated referral pathways, supported by telehealth consultation, allow rural patients from Western Australia or north Queensland to undergo testing locally while results are reviewed by a motility specialist.

Minor motility disorders such as ineffective esophageal motility should be interpreted within the broader clinical context. Treatment options include calcium channel blockers, nitrates and, in selected cases, endoscopic or surgical intervention tailored to the specific disorder and symptom burden.

Functional chest pain and hypersensitivity

When endoscopy, pH monitoring and manometry are all normal, functional chest pain becomes the likely diagnosis. The Rome IV criteria describe it as retrosternal pain with no structural explanation, understood within a biopsychosocial model of visceral hypersensitivity.

Patients respond well to clear explanation that the pain is real but reflects heightened nerve sensitivity rather than tissue damage. Cognitive behavioural therapy, delivered by psychologists familiar with functional gastrointestinal disorders, has a strong evidence base.

Pharmacological options for refractory symptoms include low-dose tricyclic antidepressants, SSRIs and SNRIs, used with realistic expectations. Referral to a functional gut disorder clinic, available in several university hospitals, supports the most complex presentations.

Diagnostic investigations in practice

The choice of investigations should be guided by clinical features rather than performed routinely. Most patients begin with an electrocardiogram and cardiac biomarkers, followed by upper endoscopy when red flags are present or reflux symptoms persist. Manometry and pH monitoring are added when symptoms remain unexplained.

The Medicare Benefits Schedule subsidises gastroscopy and pH monitoring when specific criteria are met, and clinicians should be familiar with the relevant item numbers. Private health cover can shorten waiting times, though out-of-pocket costs remain a reality for many Australian households.

Clear communication between referrer, proceduralist and the patient's general practitioner prevents duplicated testing. For Aboriginal and Torres Strait Islander patients, culturally safe care and involvement of Aboriginal health workers improves engagement and follow-through.

Building a stepwise treatment plan

Management begins with education and lifestyle modification, including meal size, late-night eating, smoking and caffeine. When reflux is suspected, a structured proton pump inhibitor trial is reasonable, with step-down once symptoms are controlled. Input from a gastroenterology-trained dietitian, available through hospital programs in Adelaide and Hobart, reinforces these measures.

For motility-related pain, options include smooth muscle relaxants and behavioural interventions, with endoscopic procedures such as pneumatic dilation or peroral myotomy reserved for select achalasia cases. Functional chest pain responds to a combined approach addressing physiology, central pain processing and psychological wellbeing. Patients benefit from regular review, allowing treatment to be tailored as symptoms evolve.

The next practical step is to map your local referral pathway, identify the nearest centre offering high-resolution manometry and ambulatory reflux testing, and establish a direct line of communication with that unit before the next unexplained chest pain case reaches your clinic.