Anxiety Disorders and the Syndrome of Chest Pain With Normal Coronary Arteries: Prevalence and Pathophysiology

Recurrent chest pain in the presence of normal coronary arteries is a common and perplexing problemin primary care medicine and cardiology and is associated with significant morbidity and healthcare utilization. A series of carefully controlled prospective studies conducted over the past decadehave suggested a strong association between this syndrome and the presence of anxiety disorders.Thirty percent to 50% of patients with recurrent chest pain and normal coronary arteries meet criteriafor panic disorder. Generalized anxiety disorder may also be associated with this syndrome. In contrast,major depression seems strongly associated with the syndrome only when it presents as a comorbiditywith panic disorder. Reluctance of nonpsychiatric physicians to diagnose and treat anxiety disordersin this population may reflect a lack of knowledge of the well-established pathophysiologicmechanisms that can mediate the association of anxiety disorders and cardiac symptoms. We proposea conceptual framework, derived from the neurologic literature and from recent studies using positronemission tomography and intravenous procaine challenge, which links anxiety and subjective cardiovascularsymptoms to abnormal activity in neural circuits involving the anterior limbic system of thebrain. This neuropsychiatric model of the role of anxiety disorders in the pathophysiology of chestpain in patients with normal coronary arteries is proposed to strengthen the rationale for the identificationand treatment of anxiety disorders in this population by nonpsychiatric physicians.