Noncardiac chest pain

Noncardiac chest pain (NCCP) affects approximately 1 quarter of the adult population in the United States. The pathophysiology of the disorder remains to be fully elucidated. Identified underlying mechanisms for esophageal pain include gastroesophageal reflux disease (GERD), esophageal dysmotility, and visceral hypersensitivity. Aggressive antireflux treatment has been the main therapeutic strategy for GERD-related NCCP. NCCP patients with or without spastic esophageal motor disorders are responsive to pain modulators. The value of botulinum toxin injection, endoscopic treatment for GERD, and antireflux surgery in alleviating NCCP symptoms is limited.     

How do we define non-cardiac chest pain?

Abstract:   Noncardiac chest pain (NCCP) is a heterogeneous disorder associated with substantial health-care costs and resource utilization. NCCP is defined by recurrent episodes of substernal chest pain in patients lacking a cardiac cause after a comprehensive evaluation. The magnitude of the problem is quite high because of fear of serious or life-threatening heart diseases. Patients with chest pain who present for the first time to ambulatory care or to the emergency room, only 11% to 39% are ultimately diagnosed with coronary artery disease. The likely causes of NCCP are numerous and often overlap. Diagnosing NCCP is difficult because NCCP remains a diagnosis of exclusion that encompasses heterogeneous patient populations. First, cardiac ischemic must be excluded and coronary angiography remains the gold standard. Once cardiac causes have been ruled out, a diagnosis of NCCP is made. Mostly, the source for NCCP originates in essence from the esophagus. Gastroesophageal reflux disease (GERD) is the most common esophageal diseases present in patients with NCCP. An initial empiric trail of high-dose acid suppression is the most cost-effective measure in the management of these patients. When a diagnostic workup is chosen, it centers on upper gastrointestinal endoscopy, 24-hr esophageal pH monitoring and esophageal manometry.     

Comparison of one-week and two-week empirical trial with a high-dose rabeprazole in non-cardiac chest pain patients

Background:  In patients with non-cardiac chest pain (NCCP), the optimal duration of an empirical trial with a high-dose proton pump inhibitor (PPI) is unclear. We aimed to compare the efficacy of one-week and two-week PPI trial in patients with weekly or more than weekly NCCP and to determine its optimal duration for diagnosing gastroesophageal reflux disease (GERD)-related NCCP.
Methods:  Forty-two patients with at least weekly NCCP were enrolled. The baseline symptoms were assessed using a daily symptom diary for seven days. Also, esophago-gastro-duodenoscopy and 24 h esophageal pH monitoring were performed for the diagnosis of GERD. Then, patients were treated with rabeprazole 20 mg twice daily for 14 days. To assess NCCP improvement during the PPI trial, the first week and the second week symptom diary were kept for 1–7 and 8–14 days. The PPI test was considered positive if a symptom score improved (50% compared to the baseline.
Results:  There was no significant difference for a positive PPI test between GERD-related NCCP group ( n  = 8, 50%) and non GERD-related NCCP group ( n  = 6, 23%) during the first week of the PPI test. However, during the second week, GERD-related NCCP had a higher positive PPI test ( n  = 13, 81%) than non GERD-related NCCP ( n  = 7, 27%) ( P  = 0.001) with a sensitivity and specificity of 81% and 62%, respectively.
Conclusions:  The rabeprazole empirical trial was diagnostic for patients with GERD-related NCCP, and its optimal duration was determined to be at least two weeks.     

Extraesophageal and atypical manifestations of GERD

Abstract   Extraesophageal manifestations of gastroesophageal reflux disease (GERD) are essentially complications of GERD that primarily involve organs that are in proximity to the esophagus. Non-cardiac chest pain (NCCP) is an atypical manifestation of GERD, because symptoms originate in essence from the esophagus. In both atypical and extraesophageal manifestation of GERD frequent heartburn is uncommon and lack of GERD symptoms is not unusual. Esophageal mucosal injury is rarely present making upper endoscopy a low-yield procedure in both conditions. While association with GERD has been commonly reported, the extent of causality remains unknown. In NCCP, the usefulness of the proton pump inhibitor (PPI) test in diagnosing GERD-related NCCP has been established. Similar value in extraesophageal manifestations of GERD has been proposed, but rarely studied. While treatment of extraesophageal manifestations of GERD remains a challenge, PPIs in at least double the standard dose, should be considered for the initial therapy. Properly designed therapeutic studies are still lacking as well as the exact role of antireflux surgery in this patient population.     

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.     

Prevalence of gastro-esophageal reflux disease in patients who attended the emergency room]

BACKGROUND AND AIMS: Gastroesophageal reflux disease (GERD) is a well-known important cause of non-cardiac chest pain (NCCP). It has been shown that in western countries this condition can be in 22-66% of the cases. However, this situation is unclear in Japanese hospitals. We performed this study to clarify the frequency of GERD in NCCP patients who attended the emergency room. METHODS: We investigated the final diagnosis of the patients with chest pain who attended the emergency room of our hospital in March, June, September and December of 2005. RESULTS: Forty patients with NCCP attended the emergency room in the study periods. In these patients, only one patient (2.5%) was diagnosed as GERD. Conclusions: The results of this study showed that the frequency of GERD in NCCP patients of emergency room of Japan is lower than that of western countries.     

Role of clinical presentation in diagnosing reflux-related non-cardiac chest pain

INTRODUCTION: Non-cardiac chest pain (NCCP) presents as a frequent diagnostic challenge, with patients tending to use a disproportionate level of health-care resources. Gastroesophageal reflux disease (GERD) is the most frequent cause of NCCP. Thus the typical symptoms of reflux, such as heartburn and regurgitation, when present as predominant symptoms are quite specific for diagnosing GERD but in patients with NCCP the clinical diagnosis of reflux is difficult, and invasive methods or the omeprazole test are required for its detection. The aim of the present study was to evaluate the role of clinical presentation when diagnosing GERD among patients with NCCP. METHODS: Patients with NCCP underwent upper endoscopy, Bernstein and omeprazole tests. The patients were divided into two groups based on GER- or non-GER-related chest pain, and clinical presentation was compared between these two groups. Gastroesophageal reflux disease was considered positive when at least two methods were positive. RESULTS: From 78 NCCP patients (41 male; mean age 50.4 +/- 2.3 years), the chest pain was related to GERD in 35 patients (44.8%). The two groups were the same based on sex and age. The chest pain severity, site, radiation and relation to food, exercise, and sleep were equal in the two groups, except for two symptoms: pain that was relieved by antacid (P < 0.031) and presence of classical reflux symptoms (P < 0.009), seen in the GERD patients. With regard to recent patient history, heartburn and regurgitation symptoms were seen more frequently in GERD patients (P < 0.036 and P < 0.002, respectively). DISCUSSION: Clinical presentation is important in diagnosing GERD in NCCP. Although the chest pain is the same in reflux- and non-reflux-related NCCP, the symptoms of heartburn or regurgitation in the present or recent patient history are diagnostic for GERD-related chest pain.     

Clinically distinct characteristics in patients younger than 40 years old with non-cardiac chest pain

Background and Aim: Little is known about non‐cardiac chest pain (NCCP) in young patients. We aimed to examine the proportion of gastroesophageal reflux disease (GERD) in young patients with NCCP compared to the average‐aged NCCP patients and to evaluate their symptomatic characteristics and the clinical efficacy of a 2‐week proton pump inhibitor (PPI) trial. Methods: Ninety‐six patients with NCCP ≥ 1/week were classified into the young‐aged (≤ 40 years, n = 38) and the average‐aged groups (> 40 years, n = 58). Typical reflux symptoms were assessed. The patients were defined into a GERD group and non‐GERD group according to reflux esophagitis on esophagogastroduodenoscopy and/or pathologic acid exposure on 24‐h esophageal pH monitoring. Then the patients were treated with 30 mg of lansoprazole bid for 14 days. Results: Nine patients (23%) in the young‐aged group and 22 patients (38%) in average‐aged group were diagnosed with GERD‐related NCCP (P = 0.144). The proportion of typical reflux symptoms was higher in the GERD group compared with the non‐GERD group in both age groups. A PPI test improved symptoms in the GERD group irrespective of age, but this improvement was not observed in non‐GERD group. Conclusions: In young NCCP patients, the prevalence of GERD was relatively low compared to average‐aged NCCP, but the difference was insignificant. The PPI test was very effective in diagnosing GERD in the NCCP patients in both age groups. Therefore, in young NCCP patients, if there is a negative response to a 2‐week PPI trial, the possibility of extra‐esophageal disease origin needs to be considered.     

食管混合性酸反流和低动力在非心源性胸痛发作的作用研究

目的胃食管反流病（GERD）是引起非心源性胸痛（NCCP）的最常见因素,本研究探讨酸反流和食管动力障碍在NCCP患者中的作用。 方法按照纳入、排除标准选取2018年9月至2019年6月在新疆维吾尔自治区人民医院急救中心以及微创,疝和腹壁外科住院收治的40例NCCP患者和50例典型GERD症状患者,两组患者均行食管24 h pH监测以及高分辨率食管测压监测。 结果NCCP组食管远端收缩平均积分（DCI）明显低于GERD组,并具有统计学意义（P＜0.05）,提示食管运动功能受损。在NCCP组患者中,与胸痛有关的混合性酸反流明显高于GERD组（P＜0.05）。在NCCP组患者中,与NCCP相关的反流发作在食管5、9和15cm处的反流清除时间比GERD组患者期长（28.3±4.21)s vs(22.6±3.28)s;(13.7±1.32)s vs (18.3±1.47)s;(9.58±1.02)s vs(14.3±1.06)s（P＜0.05）。 结论酸反流性质,食管运动功能受损和延缓反流清除时间与NCCP患者症状发作可能存在密切的关系。     

Esophageal Mast Cell Infiltration in a 32-Year-Old Woman with Noncardiac Chest Pain

Noncardiac chest pain (NCCP) is one of the most common esophageal symptoms and lacks a clearly defined mechanism. The most common cause of NCCP is gastroesophageal reflux disease (GERD). One of the accepted mechanisms of NCCP in a patient without GERD has been altered visceral sensitivity. Mast cells may play a role in visceral hypersensitivity in irritable bowel syndrome. In this case, a patient with NCCP and dysphagia who was unresponsive to proton pump inhibitor treatment had an increased esophageal mast cell infiltration and responded to 14 days of antihistamine and antileukotriene treatment. We suggest that there may be a relationship between esophageal symptoms such as NCCP and esophageal mast cell infiltration.     

Comparison of central and intraesophageal factors between gastroesophageal reflux disease (GERD) patients and those with GERD‐related noncardiac chest pain

Gastroesophageal reflux disease (GERD) causes a wide range of symptoms. Some patients present with typical symptoms such as heartburn and regurgitation and others with atypical symptoms such as chest pain. The mechanism responsible for the varying clinical presentation of GERD is still not fully elucidated. The aim of this study was to prospectively evaluate differences in central and local intraesophageal factors between patients with typical GERD symptoms and those with noncardiac chest pain (NCCP). Patients presenting with typical and atypical symptoms suspicious of GERD underwent upper endoscopy and 24‐hour pH monitoring with four sensors, each positioned at a different esophageal level. All patients completed GERD symptom, Hospital Anxiety and Depression Scale, and Symptom Stress Rating questionnaires. From January 2006 to December 2009, 50 patients were recruited, 29 with typical symptoms, and 21 with NCCP. Patients with proven GERD and NCCP had higher proximal extension of acid during reflux episodes than patients with typical symptoms. They were found to be older, had a shorter history of symptom onset, worse anxiety scores, and more endoscopic findings compatible with gastritis. Proximal extension of acid during the reflux episodes in patients with GERD presenting with NCCP may play a role in symptom generation.     

Noncardiac chest pain: evaluation and treatment

Noncardiac chest pain is a heterogeneous condition for which diagnosis and treatment are challenging. Research is needed to streamline evaluation to minimize unnecessary invasive testing and costs. Chest pain clinics to assess chest pain patients are popular in the United States and may be of value in reassuring patients and reducing presentation to hospital; however, recently this has been contended [111]. Options for the effective treatment of NCCP are dependent on the risk of an adverse outcome and the cost-effectiveness of the management algorithm that is followed. Most (64%) of those presenting to the emergency department with chest pain are classified as having NCCP [112,113]. GERD is probably the most important cause and application of a test of acid suppression with a high-dose PPI for 1 to 2 weeks seems to be a useful diagnostic tool. In those patients with GERD-related NCCP, short-term and potentially long-term therapy with a PPI (commonly higher than standard dose) is required to alleviate symptoms. Esophageal dysmotility is relatively uncommon in patients with NCCP and evaluation by esophageal manometry might be limited to rule out achalasia. Chest wall syndromes are common but probably often missed. Many patients with NCCP have psychologic or psychiatric abnormalities, as either the cause or an effect of the chest pain, but diagnosis here depends on techniques not applied easily in the acute situation. Pain modulators seem to offer significant improvement in chest pain symptoms for non-GERD-related NCCP. Finally, trials of management strategies to deal with this problem are required urgently, because the earlier discharge of patients with NCCP may exacerbate the problem. Fig. 2 provides a flow chart for diagnosis and treatment of NCCP.     

Population based study of noncardiac chest pain in southern Chinese： Prevalence, psychosocial factors and health care utilization

AIM: Population-based assessment of noncardiac chest pain (NCCP) is lacking. The aim of this study was to evaluate the prevalence, psychosocial factors and health seeking behaviour of NCCP in southern Chinese. METHODS: A total of 2 209 ethnic Hong Kong Chinese households were recruited to participate in a telephone survey to study the epidemiology of NCCP using the Rose angina questionnaire, a validated gastroesophageal reflux disease (GERD) questionnaire and the hospital anxiety-depression scale. NCCP was defined as non-exertional chest pain according to the Rose angina questionnaire and had not been diagnosed as ischaemic heart diseases by a physician. RESULTS: Chest pain over the past year was present in 454 subjects (20.6%, 95% CI 19-22), while NCCP was present in 307 subjects (13.9%, 95% CI 13-15). GERD was present in 51% of subjects with NCCP and 34% had consulted a physician for chest pain. Subjects with NCCP had a significantly higher anxiety (P<0.001) and depression score (P=0.007), and required more days off (P=0.021) than subjects with no chest pain. By multiple logistic regression analysis, female gender (OR 1.9, 95% CI 1.1-3.2), presence of GERD (OR 2.8, 95% CI 1.6-4.8), and social life being affected by NCCP (OR 6.9, 95% CI 3.3-15.9) were independent factors associated with health seeking behaviour in southern Chinese with NCCP. CONCLUSION: NCCP is a common problem in southern Chinese and associated with anxiety and depression. Female gender, GERD and social life affected by chest pain were associated with health care utilization in subjects with NCCP.     

食管内脏高敏感机制的研究

食管高敏感在非心源性胸痛患者中起重要作用,其发病机制尚不完全清楚,然而其引起的烧心、胸痛等症状严重影响患者生活质量。根据这一普遍存在的状况,此文主要探讨食管高敏感的产生机制。     

How do we define non-cardiac chest pain?

Abstract: Noncardiac chest pain (NCCP) is a heterogeneous disorder associated with substantial health-care costs and resource utilization. NCCP is defined by recurrent episodes of substernal chest pain in patients lacking a cardiac cause after a comprehensive evaluation. The magnitude of the problem is quite high because of fear of serious or life-threatening heart diseases. Patients with chest pain who present for the first time to ambulatory care or to the emergency room, only 11% to 39% are ultimately diagnosed with coronary artery disease. The likely causes of NCCP are numerous and often overlap. Diagnosing NCCP is difficult because NCCP remains a diagnosis of exclusion that encompasses heterogeneous patient populations. First, cardiac ischemic must be excluded and coronary angiography remains the gold standard. Once cardiac causes have been ruled out, a diagnosis of NCCP is made. Mostly, the source for NCCP originates in essence from the esophagus. Gastroesophageal reflux disease (GERD) is the most common esophageal diseases present in patients with NCCP. An initial empiric trail of high-dose acid suppression is the most cost-effective measure in the management of these patients. When a diagnostic workup is chosen, it centers on upper gastrointestinal endoscopy, 24-hr esophageal pH monitoring and esophageal manometry.     

Prevalence of upper gastrointestinal tract findings in patients with noncardiac chest pain versus those with gastroesophageal reflux disease (GERD)-related symptoms: results from a national endoscopic database

BACKGROUND: Available data on the prevalence of esophageal and upper gut findings in patients with noncardiac chest pain (NCCP) are scarce and limited to one center's experience. AIM: To determine the prevalence of esophageal and upper gut mucosal findings in patients undergoing upper endoscopy for NCCP only versus those with gastroesophageal reflux disease (GERD) symptoms only, using the national Clinical Outcomes Research Initiative (CORI) database. METHODS: During the study period, the CORI database received endoscopic reports from a network of 76 community, university, and Veteran Administration Health Care System (VAHCS)/military practice sites. All adult patients who underwent an upper endoscopy for NCCP only or GERD-related symptoms only were identified. Demographic characteristics and prevalence of endoscopic findings were compared between the two groups. RESULTS: A total of 3,688 consecutive patients undergoing an upper endoscopy for NCCP and 32,981 for GERD were identified. Normal upper endoscopy was noted in 44.1% of NCCP patients versus 38.8% of those with GERD (P<0.0001). Of the NCCP group, 28.6% had a hiatal hernia (HH), 19.4% erosive esophagitis (EE), 4.4% Barrett's esophagus (BE), and 3.6% stricture/stenosis. However, HH, EE, and BE were significantly more common in the GERD group as compared with the NCCP group (44.8%, 27.8%, and 9.1%, respectively, P<0.0001). In univariate analysis of patients with NCCP, male gender was a risk factor for BE (OR 1.86, 95% CI 1.35-2.55, P=0.0001) and being nonwhite was protective (OR 0.43, 95% CI 0.22-0.86, P=0.02). In this group, male gender was also a risk factor for EE (OR 1.31, 95% CI 1.11-1.54, P=0.001) and age>or=65 yr was protective (OR 0.73, 95% CI 0.6-0.89, P=0.002). The NCCP group had a significantly higher prevalence of peptic ulcer in the upper gastrointestinal tract as compared with the GERD group (2.0% vs 1.5%, P=0.01). CONCLUSIONS: In this endoscopic prevalence study, most of the endoscopic findings in NCCP were GERD related, but less common as compared with GERD patients.     

¿Cuál es la utilidad del test de inhibidores de la bomba de protones en el dolor torácico no cardíaco?

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 24 h esophageal pH monitoring before PPI testing with pantoprazole 40 mg every 12 h 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.     

Noncardiac chest pain

Opinion statement Noncardiac chest pain (NCCP) is a common condition with significant morbidity and economic implications. Psychological factors, gastroesophageal reflux disease (GERD), alteration in pain perception, and esophageal dysmotility play an important role in the pathogenesis of the disorder. Proton pump inhibitor (PPI) therapy is the most effective medical intervention for the treatment of GERD-related NCCP, as well as the most costeffective diagnostic strategy for this condition. Pain modulators such as tricyclic antidepressants, trazodone, and selective serotonin reuptake inhibitors infer a visceral analgesic effect and consequently are the treatment of choice for patients with non-GERD-related NCCP. Furthermore, cognitive behavioral therapy has also been shown to be useful in the management of subset of patients with non-GERD-related NCCP. Newer therapeutic modalities and interventions such as lower esophageal sphincter injection of botulinum toxin in NCCP patients with spastic esophageal motility disorders, theophylline, and 5-HT4 receptor agonists may supplement or replace current treatment for non-GERD-related NCCP. Future compounds may include new visceral analgesics or medications that interfere with the development of peripheral or central sensitization.     

Evaluation of symptom index in identifying gastroesophageal reflux disease-related noncardiac chest pain

BACKGROUND: Symptom index (SI), which represents the percentage of perceived gastroesophageal reflux-related symptoms that correlate with esophageal acid reflux events (pH <4), has been suggested as a measure to improve diagnosis of gastroesophageal reflux (GER)-related noncardiac chest pain (NCCP). Because no study has evaluated the value of the symptom index in NCCP patients, data to support this claim have yet to be elucidated. AIM: To evaluate the value of SI in identifying gastroesophageal reflux disease (GERD)-related NCCP patients. METHODS: Patients enrolled in this study were referred by a cardiologist after a comprehensive work-up excluded a cardiac cause for their chest pain. All patients underwent upper endoscopy to determine esophageal inflammation and 24-hour esophageal pH monitoring to assess esophageal acid exposure. Patients were instructed to record all chest pain episodes during the pH test. Patients with a positive SI (> or =50%) underwent the proton pump inhibitors (PPI) test, which is a therapeutic trial using a short course of high dose PPI. RESULTS: A total of 94 patients with NCCP were included in this study. Forty-seven (50%) had either a positive upper endoscopy or an abnormal pH test and were considered GERD-Positive. Forty-seven patients (50%) had both tests negative and were considered GERD-Negative. Total number of reflux episodes and percent total, supine and upright time pH less than 4, were significantly higher in the GERD-Positive group as compared with the GERD-Negative group (P < 0.0001, P < 0.0001, P = 0.0045, and P < 0.0001 respectively). Only 9 (19.1%) patients in the GERD-Positive group and 5 (10.6%) patients in the GERD-Negative group had a positive SI (p = ns). Eight (89%) out of the 9 patients who had a positive SI in the GERD-Positive group and 2 (40%) out of 5 patients in the GERD-Negative group responded to the PPI test. CONCLUSION: Positive SI is relatively uncommon in NCCP patients, regardless if GERD is present or absent. Hence, symptom index provides very little improvement in diagnosing GERD-related NCCP.     

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