Follow-up of patients with noncardiac chest pain

Noncardiac chest pain may be a debilitating symptom. The utility of esophageal testing to enhance patient quality of life has been inconclusive. The purpose of this study was to evaluate prospectively the impact of esophageal testing on patient well-being. Fifty-five patients undergoing esophageal testing were available for follow-up. Seventeen (31%) patients were classified in group 1: considered to have the esophagus as a likely etiology because of positive testing; 14 (25%) in group 2: possible contribution of the esophagus to symptoms; and 24 (44%) in group 3: unlikely esophageal etiology with negative testing. Thirty-four patients continued to be symptomatic at follow-up (median 112 days). The change in pain intensity from pretesting to follow-up was significant only for group 3 (P=0.001). There was a decline in hospital utilization in all three groups. (Emergency room visitsP=0.004 group 1, hospital admissionsP=0.02, group 3). Group 1 and 2 patients tended to miss less work, social functions, and activities. Group 3 continued to stay in bed and avoid normal functions. Nine of 34 (26%) patients who were symptomatic at follow-up identified the esophagus as the source of symptoms. In all, 42% of group 1, 29% of group 2, and 18% of group 3 patients considered the esophagus to be the source of their symptoms. We conclude that esophageal testing does not always prevent the persistence of symptoms and that patients have misperceptions about testing results on follow-up.This work was presented in part at the American Gastroenterological Association, New Orleans, Louisiana, May 1991.     

Treatment of noncardiac chest pain of psychological origin

Opinion statement Psychiatric comorbidity is not an uncommon phenomenon in patients with noncardiac chest pain (NCCP). Panic disorder seems to be the most important psychiatric comorbidity for a number of reasons. First, it is the most common psychiatric disorder associated with NCCP. Second, panic disorder is a highly treatable condition that can produce dramatic improvement of NCCP when treatment is appropriate. Finally, the treatment of psychiatric comorbidity, whether panic disorder or other psychiatric disorders, can pay significant dividends in terms of improving the patient’s overall well-being and adaptation to illness, even if his/her chest pain symptoms are not alleviated. Adopting a biopsychosocial model to intervene on the stress of these patients’ experience is a key concept that can make NCCP a much less formidable challenge for the gastroenterologist.     

Systematic esophageal evaluation of patients with noncardiac chest pain

We prospectively studied 73 patients with angina-like chest pain severe enough to warrant admission to a coronary care unit over a five-month period. Thirty-four patients (47%) were found to have coronary artery disease as the cause of their symptoms, based on exercise testing, stress radionuclide imaging, or cardiac catheterization. The remaining 39 patients had normal cardiac findings and then underwent videoesophagography, radionuclide esophageal transit study, and esophageal manometry. Thirty-three of the 39 underwent acid perfusion testing (modified Bernstein's test). The findings at esophageal manometry were abnormal in 29 (74%) of 39. Manometric diagnoses were "nutcracker esophagus" in 17 (59%), nonspecific esophageal motility disorders in nine (31%), diffuse esophageal spasm in two (7%), and achalasia in one (3%). Bernstein's test reproduced symptoms in only 12%. The sensitivity of videoesophagography in detecting esophageal motility disorders was 66%, and that of radionuclide esophageal transit was 79%. The positive predictive values were 86% and 85%, respectively.     

Diagnosis of noncardiac chest pain in older patients

Barium swallow and gallbladder study may reveal esophageal or gastric cancer, esophageal or duodenal ulcer, or gallstones. If serious GI tract disorders such as these are ruled out, the next step is to seek an esophageal source of recurring chest pain. Intraesophageal acid infusion and edrophonium chloride (Tensilon) stimulation can be used in the office to reproduce chest pain secondary to an esophageal disorder. With either test, reproduction of the patient's typical chest pain is positive. About one-third of patients seen in our laboratory with noncardiac chest pain have a positive response.     

Cognitive-behavioral therapy for noncardiac chest pain: a randomized trial

PURPOSE: Patients with nonischemic chest pain frequently experience recurrent symptoms, have persistent functional and occupational disability, and are high utilizers of health-care resources. Our aim was to evaluate the efficacy of a cognitive-behavioral treatment for patients with noncardiac chest pain. PATIENTS AND METHODS: Subjects were recruited from patients with at least weekly episodes of noncardiac chest pain, as diagnosed by a cardiologist. The main outcome measures were frequency and intensity of chest pain at 6 and 12 months. RESULTS: Seventy-two patients were enrolled in the study; 37 were assigned to cognitive-behavior therapy and 35 to usual care. Sixty-five patients completed the study. Intervention patients improved significantly with regard to frequency and intensity of chest pain: 15 (48%) of the 31 patients in the treatment group were pain free at 12-month follow-up compared with 4 (13%) of the 33 patients in the control group (P = 0.002). CONCLUSIONS: Cognitive-behavioral therapy for noncardiac chest pain patients was effective compared with usual care.     

Visceral hypersensitivity in noncardiac chest pain

Visceral hypersensitivity is a common cause of NCCP. Mechanoreceptors appear to be important in the pathophysiology of NCCP, although chemoreceptors also appear to play a significant role. The processing of visceral information and possibly the development of central sensitization may be important in NCCP, although the pathophysiology of NCCPremains poorly understood.     

Update on noncardiac chest pain

Patients with recurrent angina-like chest pain with normal coronary vessels are deemed to have the syndrome of noncardiac chest pain (NCCP). These patients, despite having significant cardiac disease ruled out, often spend a restricted lifestyle believing they have cardiac disease. These recurrent episodes of chest pain may be related to gastroesophageal reflux disease (GERD), spastic motility disorders of the esophagus and esophageal (visceral) hyperalgesia. These disease entities are often difficult to diagnose and treat except for GERD and achalasia. Recent prospective double-blind studies have shown that about 44% of these patients may have underlying GERD. There is now more evidence to support the practice of empiric use of proton pump inhibitors (PPIs) as the first step in therapy. Newer modalities for diagnosis like endoscopic ultrasonography (EUS) showed that this group of patients had sustained muscular contractions of longer that 68 s during chest pain. These sustained contractions noted on EUS were secondary to isometric contraction of the circular muscle which did not cause luminal constriction nor was related to contraction of the longitudinal muscles which cannot be recorded by pressure manometry. Treatment is difficult if patients do not respond to high-dose PPIs. Other medications which are known to alter visceral hyperalgesia in low doses, such as tricyclic antidepressants like imipramine and desyrel, can be tried. Psychological intervention may be useful in the management of some of these patie     

Edrophonium provocative test in noncardiac chest pain

Edrophonium chloride is used frequently as a provocative agent in the assessment of noncardiac chest pain (NCCP). However, the optimum dose and most appropriate method of interpreting test results is controversial. We studied 150 consecutive NCCP patients and 50 age-matched controls who alternately received either 80 micrograms/kg or 10 mg intravenous bolus doses of edrophonium preceded by saline placebo injections. Distal esophageal pressures were measured before and after drug injection in response to ten 5-cc wet swallows. Following 10 mg of edrophonium, 33% of patients and 4% of controls reported chest pain, while 29% of patients and no controls receiving the 80 micrograms/kg dose complained of chest pain. Amplitude changes after either dose were not significantly different for all comparisons, but the duration of response did distinguish the two doses in patients with chest pain. A significantly greater (P = 0.01) increase in distal contraction duration occurred after 10 mg (74 +/- 12%; +/- SE) compared to 80 micrograms/kg dose (43 +/- 6%). However, individual responses to the two doses overlapped considerably. If a positive test is redefined to include both chest pain and manometric changes that are significantly different from controls, the positivity rate changes drastically; 33% to 9% in the 10-mg group and 30% to 3% in the 80-micrograms/kg group. Side effects were similar between doses, but there was a significant (P = 0.02) linear relationship between intensity of side effects and the edrophonium dose per kilogram of body weight.(ABSTRACT TRUNCATED AT 250 WORDS)     

The cost-effectiveness of the omeprazole test in patients with noncardiac chest pain.

PURPOSE: Recent evidence suggests that an empiric trial of omeprazole (the "omeprazole test") is sensitive and specific for diagnosing gastroesophageal reflux disease (GERD) as the cause of noncardiac chest pain. Our objective was to examine the clinical, economic, and policy implications of alternative diagnostic strategies for patients with noncardiac chest pain. METHODS: Decision analysis was used to evaluate the clinical and economic outcomes of two diagnostic strategies that begin with the omeprazole test (60 mg daily for 7 days) followed sequentially by invasive testing utilizing endoscopy, ambulatory 24-hour esophageal pH monitoring, and esophageal manometry as necessary, compared with two traditional strategies involving sequential invasive diagnostic tests. Cost estimates were based on Medicare reimbursement and the Red Book of average wholesale drug prices. Probability estimates were derived from a systematic review of the medical literature. RESULTS: The average cost per patient for the four diagnostic strategies varied from $1,859 to $2,313. Strategies utilizing the initial omeprazole test resulted in 84% of patients being symptom free at 1 year, compared with 73% to 74% for the strategies that began with invasive tests. The strategy of the omeprazole test, followed if necessary by ambulatory pH monitoring, then manometry, and then endoscopy, was both most effective and least expensive. It led to an 11% improvement in diagnostic accuracy and a 43% reduction in the use of invasive diagnostic tests, thus yielding an average cost savings of $454 per patient, compared with the strategy of beginning with endoscopy, then pH monitoring, and then manometry. CONCLUSIONS: Among patients with noncardiac chest pain, diagnostic strategies that begin with the omeprazole test result in reduced costs, improved diagnostic certainty, and a greater proportion of symptom-free patients at 1 year than do traditional strategies that begin with invasive diagnostic tests.     

Gastroesophageal reflux disease in noncardiac chest pain

After a cardiac source has been excluded, the most likely cause of NCCP is GERD. Clinical history often cannot make the diagnosis of GERD-related NCCP. The PPI test is a simple, highly sensitive, and cost-effective tool that should be the first diagnostic test used in evaluating these patients.Patients with GERD-related NCCP require long-term therapy with a PPI,commonly double the standard dose. The introduction of the wireless pH system and the multi-channel intraluminal impedance will help us to further understand the role of GERD in NCCP. Treatment of NCCP has dramatically improved since the introduction of the PPI class of drugs.However, better therapeutic modalities should be sought out to further improve our current treatment of GERD-related NCCP.     

Esophageal perception and noncardiac chest pain

Symptoms arising from the esophagus are produced generally in one of two ways: through stimulation of chemosensitive-nociceptors (eg, through excess esophageal exposure to refluxed gastric acid or the resulting inflammation arising in acid-damaged tissue) or through stimulation of mechanosensitive nociceptors (eg, through repeated deformation or distension of the esophageal wall resulting from peristaltic or lower esophageal sphincter dysfunction). These symptoms are usually attributed in most patients to such well recognized conditions as reflux esophagitis, achalasia,etc. that subsequently result in the delivery of specific and effective treatment.However, a subset of patients exists in which the etiology of "similar-sounding symptoms" remains obscure and their responses to standard specific treatments poor. Now recognized as among this group of patients are those with visceral hypersensitivity. Visceral hypersensitivity is not itself a disease but a definable aberrant sensory response (allodynia or hyper-algesia) to end-organ stimulation. Such an aberrant sensory response is neither specific for nor limited to the esophagus, and the etiopathogenesis for its development within this organ is unknown. Nonetheless, esophageal symptoms as a manifestation of visceral hypersensitivity are increasingly recognized and worthy of attention because they identify a disorder that responds to treatment aimed at the end organ's nociceptors or their neuroanatomic pathways within the CNS.     

非心源性胸痛患者心理异常与症状间的关系

目的调查非心源性胸痛（NCCP）患者的心理精神因素异常状况，探讨它们与症状程度间的关系。方法对87例NCCP患者和健康对照组90人进行问卷调查，内容包括Zung焦虑自评量表（SAS）、Zung抑郁自评量表（SDS）、症状评分表，进行分析比较。结果1、NCCP患者焦虑、抑郁的发生率明显高于健康对照组（P〈0．005），平均焦虑、抑郁程度高于对照组（P〈0．001）。2、NCCP患者的症状积分与焦虑评分、抑郁评分呈正相关（P〈0．001）。结论焦虑和抑郁在NCCP发病机制中具有重要地位。     

The psychological aspects of noncardiac chest pain

There is some evidence to support a psychosocial link to GERD,although it is a weak one. The little research that has been done in this area is, in general, poor and inconclusive. Better designed studies must be done.The elements that seem to offer the best possibilities for research in GERD are the psychological variables involved in care seeking and the variations between care seekers and non-care seekers. In addition, research on psychosocial predictors of response to proton pump inhibitors, prokinetic agents, and antidepressants and other pain-modulating drugs need to be better understood.The psychosocial link to NCCP is stronger with regard to panic disorder,but much research needs to be done. Despite the paucity of well done,rigorously controlled studies in NCCP patients, that there is a high prevalence of psychiatric disturbance in this group. Parental health and childhood trauma are intriguing areas for further research, particularly in light of the connection between abuse and IBS and other functional GI disorders.Finally, panic disorder has been established as an important comorbidity of NCCP. It also merits more research, particularly into the pathophysiology that may link these two disorders.     

24-hour recording of esophageal pressure and pH in patients with noncardiac chest pain

Sixty patients with anginalike chest pain of noncardiac origin were studied to determine the diagnostic value of 24-h ambulatory esophageal pH and pressure monitoring. The results of these 24-h studies were compared with those obtained by established methods, including x-rays, endoscopy with biopsy, conventional esophageal manometry, and acid perfusion test. Esophageal origin of the chest pain was considered to be likely if the familiar pain sensation was reproduced by the acid perfusion test, or if the pain occurred during an episode of gastroesophageal reflux, severe motor disorders, or both. When the results of established methods were combined and interpreted according to predetermined criteria, esophageal origin of the pain was shown to be likely in 27% of the patients. The 24-h recordings, alone, showed the esophagus to be the likely cause of the pain in 35% of the patients. Combination of all conventional examinations and of 24-h recordings made esophageal origin of the pain likely in 48% of the patients.     

Diagnosis and treatment of noncardiac chest pain

Chest pain is common: one in four of the population have an episode annually. Of those who present to hospital, nearly two-thirds have noncardiac chest pain. More than half of these cases might have gastroesophageal reflux disease. Opinion differs over what is the most appropriate application of current investigatory methods. Evidence suggests that, once cardiac disease is ruled unlikely, empiric use of a proton pump inhibitor is an option; if acid suppression fails, detailed investigations as clinically indicated can be considered. A range of esophageal investigations is available, including 24-hour or 48-hour esophageal pH testing and esophageal manometry, as well as provocative tests, but there is no consensus as to which methods are the most useful. Psychiatric evaluation is not routine, but psychiatric or psychological disorders are common. Musculoskeletal disorders are also common, but are frequently overlooked. It is possible to subject patients to a comprehensive set of investigations before empiric therapy, but recent studies have failed to demonstrate an improved outcome using this exhaustive approach. A new tactic is required, with less attention spent on absolute diagnostic accuracy and more emphasis on optimizing the long-term clinical outcome in patients with noncardiac chest pain. It is possible that the targeted use of multiple drug trials in a policy of 'therapy as investigation' might be a superior methodology.     

Recent advances in noncardiac chest pain in Korea

Gastroesophageal reflux disease (GERD) is the most common cause of noncardiac chest pain (NCCP) and is present in up to 60% of patients with NCCP in Western countries. In Korea, after a reasonable cardiac evaluation, GERD is reported to underlie 41% of NCCP cases. Typical reflux symptoms are frequent in Korean patients suffering from NCCP. Therefore, a careful history of the predominant symptoms, including heartburn and acid regurgitation, is relatively indicative of the GERD diagnosis in Korea. In Korea, in contrast to Western countries, patients aged 40 years and over who have been diagnosed with NCCP but who are without alarming features should undergo endoscopy to exclude gastric cancer or peptic ulcers because of the higher prevalence of peptic ulcer disease and gastric cancers in the region. In a primary care setting, in the absence of any alarming symptoms, a symptomatic response to a trial of a proton pump inhibitor (PPI) is sufficient for the presumptive diagnosis of GERD. In addition, the optimal duration of a PPI test may be at least 2 weeks, as GERD symptoms tend to be less frequent or atypical in Korean patients than in patients from Western countries. In patients diagnosed with GERD-related NCCP, long-term therapy (more than 2 months) with double the standard dose of a PPI is required to alleviate symptoms. Esophageal dysmotility is relatively uncommon, and pain modulators seem to offer significant improvement of chest pain control in non-GERD-related NCCP. Most traditionally available tricyclics or heterocyclics have many undesirable effects. Therefore, newer drugs with fewer side effects (for example, the serotonin - norepinephrine reuptake inhibitors) may be needed.