Which of the following is the most common cause of non-cardiac chest pain? The Leading Culprits Explained

September 30, 2025 •

4 min read

It is estimated that non-cardiac causes account for over 50% of emergency department visits for chest pain. This guide addresses the key question, "Which of the following is the most common cause of non-cardiac chest pain?", by explaining the primary causes and differentiating them from heart-related issues.

Quick Summary

Gastroesophageal Reflux Disease (GERD) is the most frequent cause of non-cardiac chest pain, although other factors, including musculoskeletal problems, esophageal spasms, and anxiety, can also be responsible.

Key Points

GERD is the most common cause: Gastroesophageal Reflux Disease (GERD) is the most frequent cause of non-cardiac chest pain, responsible for an estimated 50-60% of cases.
Many other origins exist: Beyond GERD, other causes of NCCP include musculoskeletal problems (e.g., costochondritis), esophageal spasms, and psychological conditions such as anxiety and panic attacks.
Medical evaluation is essential: Any unexplained chest pain should be evaluated immediately by a doctor to rule out life-threatening cardiac causes.
NCCP mimics heart attack symptoms: Pain from NCCP, especially from esophageal issues, can be hard to distinguish from cardiac pain, as both can cause pressure or tightness behind the breastbone.
Diagnosis involves exclusion: A diagnosis of NCCP is made after heart-related causes have been thoroughly ruled out using tests like an EKG and blood work.
Lifestyle changes can provide relief: For GERD-related NCCP, modifications like avoiding trigger foods and eating smaller meals are effective. Stress reduction techniques can help manage pain caused by anxiety.

The Most Common Culprit: Gastroesophageal Reflux Disease (GERD)

After a cardiac event has been ruled out, the most common cause of non-cardiac chest pain (NCCP) is Gastroesophageal Reflux Disease, or GERD. GERD is a condition where stomach acid and other contents frequently flow back up into the esophagus (food pipe). This reflux irritates the esophageal lining, leading to a burning sensation known as heartburn. However, because the heart and esophagus are located close to each other and share a common network of sensory nerves, the pain can be "referred" to the chest, where it is often perceived as heart-related pain.

The pain can be a squeezing or pressure-like sensation, mimicking angina, and may even radiate to the neck, arm, or back, further confusing the issue. A positive response to a trial of acid-suppressing medication, such as a proton pump inhibitor (PPI), can often confirm a GERD-related diagnosis. Lifestyle changes, including dietary modifications, can also significantly help manage symptoms.

Other Significant Causes of Non-Cardiac Chest Pain

While GERD is the leader, several other conditions can cause NCCP, ranging from musculoskeletal issues to psychological factors.

Musculoskeletal Causes

The bones, muscles, and tissues of the chest wall can be a source of persistent chest pain. This type of pain often feels different from heart-related pain, presenting as localized tenderness that worsens with movement or pressure. Common musculoskeletal culprits include:

Costochondritis: Inflammation of the cartilage that connects a rib to the breastbone.
Muscle Strains: Injuries to the chest muscles from heavy lifting, strenuous exercise, or repetitive movements.
Rib Fractures or Bruises: Traumatic injuries to the ribs.
Fibromyalgia: A chronic pain syndrome that can include chest wall tenderness.

Esophageal Motility Disorders

Problems with the muscular contractions of the esophagus can also lead to chest pain. These disorders are less frequent than GERD but can cause significant discomfort. Conditions include:

Esophageal Spasms: Abnormal, powerful, or uncoordinated muscle contractions in the esophageal wall.
Achalasia: A rare disorder where the lower esophageal sphincter fails to relax, causing food to back up.
Esophageal Hypersensitivity: A condition where the nerves in the esophagus are overly sensitive to normal sensations like minimal acid exposure or pressure changes.

Psychological Factors

Mental health conditions are significant contributors to NCCP. The mind-body connection can cause emotional distress to manifest as physical pain. Psychological causes can be particularly difficult to manage, as symptoms often persist even after a cardiac workup is negative. These factors include:

Panic and Anxiety Disorders: The "fight or flight" response can lead to physical symptoms like increased heart rate, hyperventilation, and chest tightness or spasms.
Depression: This condition can cause a range of physical symptoms, including unexplained pain.
Stress: Chronic stress can exacerbate or trigger pain perception, particularly in those with other functional pain disorders.

A Comparison of Cardiac and Non-Cardiac Chest Pain

It is often difficult to distinguish between cardiac and non-cardiac chest pain based on symptoms alone. Always seek immediate medical attention for new or severe chest pain. However, some general differences can provide clues.


Feature	Cardiac Chest Pain (Angina)	Non-Cardiac Chest Pain (NCCP)
Sensation	Squeezing, tightness, heavy pressure, or fullness	Sharp, burning, stabbing, or aching pain
Location	Typically in the center or left side of the chest, may radiate to the arm, jaw, neck, or back	Can be localized to a specific spot, often behind the breastbone
Triggers	Often triggered by physical exertion or emotional stress	May be triggered by eating certain foods, stress, or movement
Duration	Lasts a few minutes, typically subsides with rest or nitroglycerin	Variable duration; can last seconds, hours, or be chronic
Relief	Improves with rest or heart medication	May be relieved by antacids, muscle relaxants, or relaxation
Associated Symptoms	Sweating, nausea, shortness of breath, dizziness	Heartburn, regurgitation, difficulty swallowing, or anxiety symptoms

The Diagnostic and Treatment Journey

Diagnosing NCCP is a process of exclusion, starting with the immediate ruling out of cardiac conditions in an emergency setting. Common tests for cardiac evaluation include:

Electrocardiogram (EKG/ECG): To measure the heart's electrical activity.
Blood Tests: To check for heart muscle damage markers like troponin.
Stress Test: To assess heart function during physical activity.

Once heart disease is excluded, a provider might refer the patient to a gastroenterologist to investigate esophageal causes. Diagnostic tests may include:

Upper Endoscopy: A procedure using a thin scope to visualize the esophagus and stomach.
Esophageal pH Test: To measure the amount of acid exposure in the esophagus over 24 hours.
Esophageal Manometry: To measure the pressure and coordination of muscle contractions in the esophagus.

Treatment is tailored to the specific cause. For GERD-related NCCP, acid-reducing medications and dietary changes are primary. For musculoskeletal issues, anti-inflammatory drugs, rest, and physical therapy are often recommended. In cases involving psychological factors, treatments may include medication, psychotherapy, and stress-reduction techniques.

Conclusion

The question "Which of the following is the most common cause of non-cardiac chest pain?" has a clear answer, with GERD topping the list. However, the multifaceted nature of NCCP means that causes can range from digestive and musculoskeletal issues to psychological distress. Because the pain can be difficult to differentiate from a heart attack, it is critical to seek professional medical evaluation for any new or alarming chest pain. A proper diagnosis is the first step toward effective management and relief from this often-distressing condition.

For more information on GERD and related symptoms, refer to the Cleveland Clinic's resources on noncardiac chest pain.

Frequently Asked Questions

A healthcare provider will first rule out cardiac causes with tests like an EKG and blood tests. Once heart issues are excluded, they may investigate other potential sources, such as gastrointestinal problems with procedures like an endoscopy or pH test.

Yes, anxiety and panic attacks are common causes of non-cardiac chest pain. The body's stress response can lead to physical symptoms like increased heart rate, muscle tension, and spasms in the chest.

Musculoskeletal pain is often localized to a specific spot, and may be sharp, aching, or stabbing. It frequently worsens when pressing on the area or with certain movements, coughing, or deep breaths.

It is often difficult and requires a medical professional. Generally, cardiac pain is more often a heavy, crushing pressure triggered by exertion, while NCCP might be sharp, burning, and affected by position or eating. Any new or severe chest pain should prompt immediate medical evaluation.

Yes, a provider may prescribe a trial of a Proton Pump Inhibitor (PPI). If the chest pain improves with the medication, it strongly suggests that GERD is the cause of the pain.

Non-cardiac chest pain can become a chronic and recurring issue for many people. While not usually life-threatening, it can significantly impact a person's quality of life.

Always seek immediate medical attention for any new, severe, or unexplained chest pain to ensure a proper diagnosis and rule out a heart attack. Healthcare professionals can differentiate between cardiac and non-cardiac causes.