USMLE Step 3 - Question 46

A 62 year old male with a history of hypertension presents to the emergency room with recurrent chest pains. He has been seen on numerous occasions for these symptoms and no etiology has been discovered. His medications include aspirin, metoprolol, and omeprazole. His temperature is 37.0, blood pressure 120/80, heart rate 80, and respirations 20. Physical examination is normal without any chest wall tenderness. ECG during the chest pain is normal. Laboratory studies are normal. He undergoes coronary angiography, esophagogastroduoenoscopy, and pulmonary function testing all of which are normal. Which of the following is the best treatment?

A. Psychiatric referral

B. Amitriptyline

C. Pantoprazole

D. Ibuprofen

This patient is experiencing non-cardiac chest pains. The goal should be to rule-out any specific cause such as gastroesophageal reflux disease or pulmonary disease. Once done adequately, treatment with a tricyclic antidepressant for non-specific “visceral” chest pains can be initiated which is marginally effective. There are some other situations where patients can have anginal chest pains despite normal physical exam findings and normal angiographic coronary arteries. These include coronary vasospasm, Syndrome X and DaCosta's syndrome.