Management of noncardiac chest pain in women

Chest Pain: If It Is Not the Heart, What Is It?

Noncardiac chest pain is an angina-type discomfort without indication of ischemia. Diagnosis can be difficult because of its heterogeneous nature. Classification varies by specialty; gastroenterology uses the terminology gastroesophageal reflux disease related versus non-gastroesophageal reflux disease related. Other disciplines recognize noncardiac chest pain etiologies as having gastrointestinal, musculoskeletal, psychiatric, or pulmonary/other as underlying etiologies. Diagnostics yield a specific cause for effective treatment, which is aimed at the underlying etiology, but it is not always possible. Some patients with noncardiac chest pain have comorbidities and ongoing pain that lead to decreased quality of life and continued health care use.

Prevalence of Gastrointestinal Diseases and Treatment Status in Noncardiac Chest Pain Patients

Background and Objectives

We evaluated the prevalence of gastroesophageal reflux diseases (GERD) in noncardiac chest pain (NCCP) patients, risk factors for GERD, and status of prescriptions for GERD in Korean population.

Subjects and Methods

This was a retrospective non-interventional observational nation-wide 45-center study. Patients with a normal coronary angiogram (CAG) and upper gastroendoscopy within 2 years after CAG were enrolled. The prevalence of GERD was examined. Other gastrointestinal diseases including peptic ulcer diseases or gastritis were also examined. Risk factors for GERD were compared between the GERD group and non-GERD group. The ratio of patients medicated for gastrointestinal diseases (antacids or proton-pump inhibitor) was also examined.

Results

Nine hundred four patients were enrolled. Among the NCCP patients, GERD was present in 436 (48.2%), peptic ulcer disease in 154 patients (17.0%), and gastritis in 659 (72.9%). There was no difference in risk factors for GERD between the GERD and non-GERD patients. Medications for GERD and other gastrointestinal diseases were prescribed in 742 (82.1%) patients.

Conclusion

GERD was common (42.8%) in Korean NCCP patients and most (82.1%) received the prescription of gastrointestinal medications. No differences were evident in risk factors between GERD and non-GERD patients.

[What is the utility of proton pump inhibitor testing in non-cardiac chest pain?]

BACKGROUND AND AIMS

Noncardiac chest pain (NCCP) often represents a diagnostic and therapeutic challenge. Given that gastroesophageal reflux disease (GERD) is the most common cause of NCCP, initial treatment with proton-pump inhibitors (PPI) has been proposed for all patients (PPI testing), reserving esophageal function testing solely for non-responders. The aim of the present study was to provide evidence on the clinical utility of PPI testing with high-dose pantoprazole in patients with NCCP.

PATIENTS AND METHODS

We carried out a study of diagnostic performance with a cohort design in patients with NCCP, who had been assessed by the Cardiology Service. All patients underwent upper endoscopy, esophageal manometry, and 24h esophageal pH monitoring before PPI testing with pantoprazole 40 mg every 12h for 1 month. Before and after treatment, we assessed the severity (intensity and frequency) of chest pain, quality of life, and anxiety and depression by means of specific questionnaires. The diagnosis of GERD was based on a pathological finding of esophageal pH monitoring. A positive response to PPI testing was defined as an improvement in chest pain >50% compared with the baseline score after 1 month of PPI therapy.

RESULTS

We included 30 consecutive patients (17 men/13 women) with a mean age of 49 years. Of these 30 patients, 20 with NCCP had GERD (67%, 95%CI: 47%-83%). A positive response to PPI therapy was observed in 13 of the 30 (43%) patients with NCCP: 11 of the 20 (55%) patients in the GERD-positive group and 2 of the 10 (20%) in the GERD-negative group. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of PPI testing was 55%, 80%, 85%, 47% and 63%, respectively. A significant reduction in chest pain after pantoprazole therapy (P=.003) and a slight non significant improvement in anxiety and depression was achieved in the GERD-positive group as compared to the GERD-negative group.

CONCLUSIONS

In NCCP, PPI testing with pantoprazole has a low sensitivity for the diagnosis of GERD, placing in doubt the strategy of reserving functional study to non-responders to antisecretory therapy. Esophageal function testing and accurate diagnosis would allow appropriate targeted therapy for all patients with NCCP.