Angina-like chest pain of oesophageal origin

Roles of gastro-oesophageal afferents in the mechanisms and symptoms of reflux disease

Oesophageal pain is one of the most common reasons for physician consultation and/or seeking medication. It is most often caused by acid reflux from the stomach, but can also result from contractions of the oesophageal muscle. Different forms of pain are evoked by oesophageal acid, including heartburn and non-cardiac chest pain, but the basic mechanisms and pathways by which these are generated remain to be elucidated. Both vagal and spinal afferent pathways are implicated by basic research. The sensitivity of afferent fibres within these pathways may become altered after acid-induced inflammation and damage, but the severity of symptoms in humans does not necessarily correlate with the degree of inflammation. Gastro-oesophageal reflux disease (GORD) is caused by transient relaxations of the lower oesophageal sphincter, which are triggered by activation of gastric vagal mechanoreceptors. Vagal afferents are therefore an emerging therapeutic target for GORD. Pain in the absence of excess acid reflux remains a major challenge for treatment.

Diagnosis of reflux disease

There are numerous tests for which a diagnostic value in the context of gastro-oesophageal reflux disease has been claimed. Some of these tests (e.g. the acid perfusion test) have become obsolete after the advent of 24-hour oesophageal pH monitoring. With the latter test not only can excessive reflux be identified, but also, and more importantly, a temporal relationship can be demonstrated between a patient's symptoms and reflux episodes. Radiographical examination of the oesophagus has largely been replaced by endoscopy, although the use of the former test is still indicated in certain circumstances (e.g. in the differentiation of sliding from para-oesophageal hiatus hernia). In clinical practice, the so-called proton pump inhibitor test has gained considerable popularity. Despite several studies on the specificity and sensitivity of this test, its value has not yet been established with sufficient accuracy. Conventional manometric evaluation of lower oesophageal sphincter pressure has been over-emphasized as a diagnostic test in gastro-oesophageal reflux disease.

Chest symptoms after sumatriptan: a two-year clinical practice review in 735 consecutive migraine patients

OBJECTIVES

To assess, in clinical practice, the (i) incidence, (ii) within-patient consistency, and (iii) clinical spectrum of chest symptoms (chest symptoms) after subcutaneous (sc) and oral sumatriptan, and (iv) to identify risk factors for chest symptoms.

DESIGN

Two-year retrospective survey with mailed self-administered questionnaire.

SETTING

Neurology outpatient clinic of university hospital.

SUBJECTS

Migraine patients with or without aura (n = 869).

MAIN OUTCOME MEASURES

Incidence, within-patient consistency and characteristics of chest symptoms; demographic and clinical characteristics of patients.

RESULTS

There were 735 (85%) respondents. Sumatriptan was used by 453 patients, during 25 months (median), for 28000 attacks (median: 33 attacks/patient). Of sumatriptan users, 41% (sc) and 24% (oral) had chest symptoms in all attacks, 39% (sc) and 58% (oral) in none, and the remaining in some attacks. Because of chest symptoms, 10% discontinued sumatriptan. Chest symptoms mostly consisted of heavy arms and chest pressure, started within 5 (sc) to 30 (oral) min, and lasted 30 (sc) to 60 (oral) min. Compared with patients without chest symptoms, patients with chest symptoms more often were females and younger, and went to rest immediately after sumatriptan administration (all p < 0.001); they also tended to have lower body mass indices, more severe attacks and less efficacy of sumatriptan (all 0.001 < p < 0.05). Patients with chest symptoms had no higher incidence of cardiovascular symptoms or risk factors.

CONCLUSIONS

Chest symptoms are frequent, within-patients consistent, but rarely important, adverse events of (notably sc) sumatriptan. The risk of chest symptoms is patient-dependent and not related, even opposite, to cardiovascular disease. This contradicts the hypothesis that chest symptoms after sumatriptan are caused by cardiac ischemia. Patient acceptance of chest symptoms is improved by pre-advising on the risk and nature of chest symptoms.

Adverse reactions attributed to sumatriptan. A postmarketing study in general practice

There are several reports on cardiac adverse reactions attributed to the antimigraine drug sumatriptan in the recent literature. In order to assess the frequency and the character of adverse reactions to sumatriptan, a postmarketing cohort study was performed one year after registration of the drug in The Netherlands. With assistance of 86% of the drug dispensing general practitioners in The Netherlands, 1727 patients who had received sumatriptan were traced in July, 1992. Via their general practitioners, a questionnaire about use of sumatriptan, adverse reactions and other medication was sent to the patients in December 1992. During the study period, seven patients were lost to follow-up. Of the 1720 remaining patients, 1202 (70%) responded to the questionnaire, of whom 1187 had actually used sumatriptan. The most frequently reported suspected adverse reactions were paraesthesiae (139 patients, 95% CI 9.9%-13.5%) and dizziness (96 patients, 95% CI 6.5%-9.7%). Chest pain after use of sumatriptan was reported by 94 patients (7.9%, 95% CI 6.4%-9.4%), and according to the close temporal relationship with the intake of sumatriptan and a positive rechallenge, a causal relationship was probable in most of those patients. The frequency of chest pain attributed to sumatriptan was higher in females (9.0% vs 4.6%; relative risk 1.9, 95% CI 1.1-3.4). Age and hypertension were not associated with chest pain attributed to sumatriptan. Dyspnoea attributed to sumatriptan was reported by 26 patients (2.2%), and was associated with obstructive lung disease (relative risk 5.4 95% CI 1.7-16.9).(ABSTRACT TRUNCATED AT 250 WORDS)

Acute noncardiac chest pain in a coronary care unit. Evaluation by 24-hour pressure and pH recording of the esophagus

Twenty-four-hour recording of esophageal pressure and pH was performed successfully in 41 patients admitted to the coronary care unit of a general hospital who had an episode of acute, prolonged retrosternal chest pain and who were initially suspected of suffering from coronary artery disease (severe angina pectoris, myocardial infarction), but in whom the pain was subsequently shown not to be of cardiac origin. The recordings were analyzed with fully automated techniques. A pain episode was considered to be related to abnormal esophageal motility when contraction amplitudes or durations in the pain episode exceeded the patient's upper limit of normal (97.5th percentile) or when the proportion of abnormal propagated contractions (simultaneous, nontransmitted) in the pain episode was significantly increased (chi 2 test). Thirty patients (73%) had one or more pain episodes (in total 63 pain episodes) during the 24-hour recording. Forty-three percent of the pain episodes was related to abnormal motility and 30% to reflux, and 27% was not related to esophageal function disturbance. Using the criterium that the symptom index had to be greater than or equal to 75%, it was found that the pain was related to reflux in 13 patients (43%) and to motor abnormalities in 10 patients (33%). It is concluded that in the majority of patients acutely admitted with noncardiac chest pain, esophageal motor abnormalities and reflux can be shown to be the likely cause of the symptoms.

Analysis of 24-hour esophageal pressure and pH data in unselected patients with noncardiac chest pain

Fourty-four unselected patients with noncardiac chest pain were studied using conventional manometry with additional edrophonium provocation and 24-hour ambulatory esophageal pH and pressure recording with a system developed by our group. New, fully automated techniques of statistical analysis of the complete set of esophageal pressure and pH signals were used to examine the temporal relation between pain, esophageal motility disturbances, and gastroesophageal reflux. The analysis used the 97.5th percentile of amplitude and duration of all esophageal contractions in each patient as well as a chi 2 test of the distribution of contraction types to determine whether a pain episode was related to abnormal motility or not. The edrophonium test results were positive in 2 patients. Only 25 patients (56.8%) had at least one pain episode (total, 111 episodes) during 24-hour recording. Thirty-three percent of the pain episodes were related to reflux and 23.4% to abnormal motility, and 43.2% were not related to an esophageal function disturbance. In the patient-oriented analysis in this study, it was required for a positive correlation that the symptom index (percentage of related pain episodes) was higher than 75%. It was found that the pain was related to reflux in 2 patients (4.6%), to reflux and motor abnormalities in 4 (9.2%), and to motor abnormalities in 2 patients (4.6%). In 36 patients (81.8%), no relation with an esophageal abnormality could be established, either because the patients had no pain during the 24-hour study, or because the pain seemed unrelated to reflux or abnormal motility.

Pathophysiology of reflux esophagitis

Prolonged (24 h) intra-esophageal pH measurements have shown that short-lasting reflux episodes regularly occur in normal subjects, especially in the postprandial period. This phenomenon has been called physiological reflux. When the reflux episodes become more frequent and last longer, symptoms and esophagitis ensue. The mechanism of symptom production (pyrosis and/or chest pain) is incompletely understood. Chemoreceptors are involved but manometric disturbances and irritability of the esophagus may play an important role. The pathogenesis of pathological reflux is multifactorial: 1. An ineffective anti-reflux barrier at the level of the gastroesophageal junction is the most important factor in the pathogenesis of reflux. 2. Once reflux has occurred, an appropriate clearing of the refluxed material is necessary to minimize the contact time of the noxious agent with the esophageal mucosa. This clearing function is a two-step operation. In the refluxed material the concentration of H+ is the most irritant factor although pepsine increases its noxious character. Bile acid reflux decreases the epithelial resistance. The mucosal resistance to noxious agents is determined by the mucous layer, the cytoprotective properties of the epithelium, the regeneration capacity of the cells and by a number of post-epithelial factors.