• Medically unexplained chest pain (MUCP) refers to persistent or recurrent chest pain for which no clear organic cause can be identified after appropriate medical evaluation.
• It is often associated with psychological factors, functional disorders, and heightened pain perception.
• Also termed non-cardiac chest pain when cardiac causes have been excluded.

• Medically Unexplained Chest Pain Clinical Epidemiology
• Risk Factors: Psychological conditions such as anxiety and panic disorder, heightened pain sensitivity, history of functional somatic syndromes (e.g., irritable bowel syndrome, fibromyalgia), autonomic dysregulation, and prior negative healthcare experiences increase the risk of Medically Unexplained Chest Pain.
• Prevention: Early recognition and management of anxiety and psychological distress, patient education on the benign nature of symptoms, cognitive-behavioural therapy (CBT) for at-risk individuals, and promoting healthy coping mechanisms for stress may reduce the risk of developing chronic unexplained chest pain.

• Increased visceral sensitivity: Hypersensitivity of oesophageal or cardiac nociceptors leading to amplified pain perception.
• Altered central pain processing: Functional MRI studies suggest increased activation of pain-processing areas.
• Autonomic dysfunction: Imbalance in sympathetic and parasympathetic nervous systems contributing to chest discomfort.
• Psychological factors: Anxiety, panic disorder, and somatisation contribute to symptom generation.

• Acute episodes lasting minutes to hours, often recurrent.
• May be persistent over months or years in some patients.
• Symptoms may fluctuate in severity depending on stress and psychological state.

• Chest pain – Often described as sharp, stabbing, or burning. Lacks a clear cardiac pattern.
• Dyspnoea – Likely due to associated anxiety and hyperventilation.
• Palpitations – Secondary to heightened autonomic arousal.
• Globus sensation – Feeling of a lump in the throat, commonly linked to oesophageal hypersensitivity.
• Reflux symptoms – May mimic cardiac pain due to shared neural pathways.

• Normal cardiovascular examination – No signs of cardiac pathology.
• Hyperventilation signs – Rapid breathing, dizziness, and tingling in fingers.
• Psychological distress – Anxious affect, sweating, and restlessness.

• Exertional chest pain – Suggests underlying ischaemic heart disease.
• Syncope – Could indicate arrhythmias or structural heart disease.
• Neurological symptoms – Consider stroke or aortic dissection.
• Progressive weight loss – Raises suspicion of malignancy.

• Epigastric pain mimicking angina.
• Chronic pain with no acute exacerbations.
• Pain triggered by emotional stress without exertion.

• ECG – Normal in medically unexplained chest pain but done to rule out ischaemia.
• Troponins – Normal unless coincidental pathology.
• Oesophageal pH testing – May detect reflux.
• Psychological assessment – Useful for identifying underlying anxiety or panic disorder.

35-year-old female with recurrent, non-exertional chest pain, associated with anxiety and palpitations, normal ECG and troponins.

• Gastro-oesophageal reflux disease (GORD) – Pain often related to meals, associated with heartburn.
• Panic disorder – Chest tightness with severe anxiety and hyperventilation.
• Costochondritis – Localised tenderness over the costal cartilage.
• Coronary artery disease – Exertional pain, relieved by rest.

• Reassurance and explanation of non-cardiac origin.
• Cognitive-behavioural therapy (CBT) for anxiety-related symptoms.
• Selective serotonin reuptake inhibitors (SSRIs) if anxiety is prominent.
• Proton pump inhibitors (PPIs) if reflux suspected.

• Chronic pain syndrome.
• Repeated unnecessary medical investigations.
• Reduced quality of life due to persistent symptoms.