Esophageal dysfunction in patients with atypical chest pain investigated with esophageal scintigraphy and myocardial perfusion imaging: An outcome study

BACKGROUND: The objectives of this study were to determine the role of esophageal scintigraphy (ES) and myocardial perfusion imaging (MPI) in patients with atypical chest pain investigated for ischemic heart disease (IHD). METHODS AND RESULTS: One hundred five consecutive patients with atypical chest pain were investigated by dual-isotope MPI (1-day rest-stress protocol). Within a 10-day period, each patient also had liquid and semisolid ES performed with dynamic imaging over a 2-minute period for each phase. All patients were risk-stratified, and 28 patients were also investigated by coronary angiography. Patient outcome was assessed with the use of endpoints including cardiac death, myocardial infarction, and coronary revascularization procedures. Of the patients, 53 (50%) had esophageal dysfunction (ED) but no IHD, 41 (39%) had both ED and IHD, 5 (5%) had normal ES and IHD, and 6 (6%) had neither ED nor IHD. On the basis of outcome findings (n = 105) and coronary angiogram results (n = 28), MPI showed sensitivity for the detection of IHD of 92% in this patient population. Of the 94 patients (89%) with ED, 48 (51%) showed esophageal dysmotility, 9 (10%) showed gastroesophageal reflux, 17 (18%) showed esophageal spasm and dysmotility, 17 (18%) showed both reflux and dysmotility, and 3 showed other abnormalities. The median follow-up period after MPI was 20 months (range, 9-30 months). Twenty-one patients had cardiac events. These included 2 cardiac deaths, 2 myocardial infarctions, 6 coronary artery bypass graft surgeries, and 11 angioplasty/stent procedures. All but 2 of these patients had abnormal ES studies, and 7 had no prior history of IHD. MPI detected IHD in all but 2 of these patients. CONCLUSIONS: There is a high incidence of ED in patients with atypical chest pain referred for cardiologic assessment. The low proportion of patients with IHD alone and of those with neither IHD nor ED presenting with atypical chest pain (5%), as well as the high proportion with ED alone (50%), indicates the high likelihood of chest pain derived from ED. However, of the 21 patients with cardiac events, 7 had no prior history of IHD, indicating the importance of the use of MPI in the investigation of patients with atypical chest pain syndromes.