A 34-year-old man is being evaluated for a 3-month history of chest pain. He describes frequent episodes of substernal squeezing-type chest discomfort that radiates to his neck. The episodes are not related to any particular activity, often occur at rest, and last up to 2 hours. He has no shortness of breath, wheezing, palpitations, syncope, or leg swelling. The patient does not use tobacco, alcohol, or illicit drugs. Family history is unremarkable. His blood pressure is 123/72 mm Hg, and pulse is 76/min. BMI is 32 kg/m². ECG is normal. Exercise stress test shows no abnormalities. Which of the following is the most likely cause of this patient's chest pain?

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11ec25c8_d34d_7bd7_bc81_bfe072f27638_MD0003_00 This patient has recurrent episodes of prolonged chest pain over several months that are not associated with activity or other accompanying symptoms. His physical examination, ECG, and exercise stress test are unremarkable. These findings are suggestive of an underlying esophageal disorder. Gastroesophageal reflux disease (GERD) and esophageal motility disorders are common causes of non-cardiac chest pain. Esophageal motility abnormalities usually manifest as heartburn, dysphagia, food regurgitation, and/or chest pain. Features suggestive of an esophageal origin of chest pain include prolonged pain lasting >1 hour, postprandial symptoms, associated heartburn or dysphagia, and relief of pain by antireflux therapy. Definitive diagnosis of esophageal chest pain is often challenging, and many patients first require cardiac testing to exclude myocardial ischemia. (Choice A) This patient has no risk factors or clinical features suggestive of acute aortic disease (eg, aortic dissection, intramural aortic hematoma) as a cause of his symptoms. (Choice B) This patient is young, has prolonged episodes of chest pain at rest without any physical activity or exertion, and had a normal stress test. This goes against the diagnosis of coronary artery disease. Coronary artery vasospasm (Prinzmetal angina) can cause recurrent attacks of chest pain, but these usually last a few minutes (rather than >1 hour); cigarette smoking is a significant risk factor. (Choice D) Musculoskeletal or chest wall pain is the most common cause of chest pain in the primary care setting. The chest pain is typically sharp, localized to a specific area over the chest wall, and may be reproducible or aggravated by movement or change in position. (Choice E) Pleuritic chest pain is typically sharp and stabbing in nature, worsens with deep inspiration, and is occasionally accompanied by pleural rub on physical examination. (Choice F) Pulmonary hypertension occurs in patients with long-standing primary pulmonary or cardiac disease. Most patients have associated symptoms of dyspnea on exertion, fatigue, or lower-extremity edema. Educational objective: Gastroesophageal reflux disease (GERD) and esophageal motility disorders are common causes of non-cardiac chest pain. Features suggestive of an esophageal origin of chest pain include prolonged episodes lasting more than an hour, postprandial symptoms, associated heartburn or dysphagia, and relief of pain by antireflux therapy. References: Emergency department and office-based evaluation of patients with chest pain. (http://www.ncbi.nlm.nih.gov/pubmed/20194155) Noncardiac chest pain: diagnostic evaluation. (http://www.ncbi.nlm.nih.gov/pubmed/21777340)

A 34-Year-Old Man Is Being Evaluated for a 3-Month History