Physical tests for noncardiac chest pain.

    Non-cardiac chest pain is a major problem in general practice, in outpatients, and on the wards. Some patients are “reassured” that their pain is not cardiac but this is of course not the end of the matter. Some are given the label “musculoskeletal” but this is not very convincing without a clear explanation.


    Coronary disease and inflammatory spinal disease can co-exist and this physical sign does not exclude angina but its presence in the absence of any objective evidence of myocardial ischaemia—for example, no ECG changes during pain, is helpful in the differential diagnosis.

    The main underlying mechanisms include gastroesophageal reflux, esophageal dysmotility, and esophageal hypersensitivity. Gastroesophageal reflux disease is likely the most common cause of noncardiac chest pain. There are many causes for NCCP, and they are not limited to the esophagus.

    Thus, the term NCCP is more inclusive and includes musculoskeletal, pulmonary, cardiovascular, infectious, drug-related, psychological and other GI disorders.

    When it comes to chest pain, the cardiologist's first priority is to exclude any acute life-threatening cardiovascular condition.

    These include acute myocardial infarction, unstable angina, aortic dissection, pulmonary thromboembolism and pericardial tamponade. If an acute cardiac syndrome has been excluded, then evaluation for chronic ischemic heart disease or pericardial disease should be pursued. Various tests can help determine the presence and severity of ischemia, left ventricular function, appearance of the coronary arteries and functional capacity. They include exercise electrocardiogram or exercise echocardiography, echocardiography or nuclear SPECT and, if patients are unable to exercise, pharmacologic (dobutamine, persantine or adenosine) echocardiography, nuclear SPECT or cardiac MRI. 
   Here some useful tests for bedside physical examination:

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