Non-Cardiac Chest Pain – AMHE
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Transcript Non-Cardiac Chest Pain – AMHE
NON-CARDIAC
CHEST PAIN
Alix Lanoue, MD
Gastroenterologist in private practice
Hollywood, Florida
Case Study
37 yo woman w 6 months of recurring chest pain-many ER
visits.
Average of one episode per week. Occurs mainly in
daytime. No trauma
Burning, Crushing, substernal, radiates to both arms
No odynophagia, dysphagia, nausea, vomiting or typical
heartburn sx.
Negative cardiac and pulmonary work-ups.
PMH- Obesity, HTN, Depression, distant hx of PUD
PSH: hospitalized for chest pain 2 months ago- negative
cardiac cath.
All: NKDA
Meds: Lopressor, 81 mg Aspirin- no herbals/NSAIDS
FHx: Father died of heart disease/ mother has HTN
ROS: pos for SOB, palpitations, depression and anxiety.
Denies cough, wheezing, hemoptysis fever or chills.
Social: No vices
Case Cont
BP 120/68 WT 236 lbs BMI 38
pulse 72
HEENT: NCAT
Lungs: CTAB, No rib tenderness.
CV: RRR, S1 and S2. No rubs, murmurs or
gallops.
ABD: NABS, soft, Nontender, nondisted, no
organomegaly
Ext: No c/c/e. no joint abnormalities
Skin: intact except for mild hirsutism.
Neuro: AAOx3, nonfocal
Non-Cardiac Chest Pain (NCCP)
Definition
Chest pain that resembles heart pain in
patients who have no heart disease
Other terms used to describe this
condition are:
*Atypical chest pain
*Chest pain of undetermined origin
*functional chest pain
*Chest pain with normal coronary
angiogram
*Unexplained chest pain
*DaCosta’s syndrome
Epidemiology
One community-based study found the prevalence of
NCCP to be as high as 23%.¹
A population-based study found that 66 to 90% of pts
presenting to ED with chest pain were not of cardiac
origin.²
Prevalence is equal in women and men but women seek
medical attention more commonly.¹׳³
Chest pain is a very common presentation and puts a
burden, both in cost and time, to emergency care
delivery.
One year after they ruled out for CAD by angiogram,
one survey found that 47% limited their activities, 51%
were unable to work and 44% still believed they had
CAD.4
1. Locke et al. Gastroenterology. 1997;112:1448-1456.
2. Katerndahl et al. J Fam Pract. 1997;45:54-63.
3. Fass et al. Curr Opin Gastroenterol. 2001;17:376-380.
4. Ockene et al. NEJM. 1980;303:1249.
Presentation
Burning, squeezing, crushing substernal
chest pain
Radiation to the arms, neck, back and
jaws
Improves with sublingual
nitroglycerin/antacids
Can be accompanied by dyspnea,
pleurisy
Essentially, clinical symptoms cannot
differentiate cardiac chest pain from
NCCP.
Differential
Non-Ischemic
Cardiovascular
Aortic Dissection
Myocarditis
Pericarditis
Pulmonary
Pleuritis
Pneumonia
Pulmonary embolus
Tension pneumothorax
Chest Wall
Cervical disc disease
Costochondritis*
Fibrositis
Herpes Zoster( before
rash)
Neuropathic pain
Rib fracture
Sternoclavicular arthritis
Psychiatric
Affective disorders
Anxiety disorders
Somatoform disorders
Differential cont
Gastrointestinal
Nonesophageal
Biliary
Peptic
ulcer
disease
pancreatitis
Esophageal
Reflux
diseases
Esophageal
spasm
Esophageal
hypersensitivity
Pill esophagitis
HIV-AIDS
diseases
Lye ingestion
Achalasia
Impression
Non-cardiac chest pain most likely of
esophageal origin.
Pathophysiology
Pathological acid reflux
Non-acid reflux
Disturbed Motility
Visceral hypersensitivity/Brain-gut interactions
Chemoreceptor, mechanoreceptor, thermoreceptor
malfunction
Altered cerebral processing of sensory data
Psychological abnormalities- somatoform disorder
Next Step
What should be done next?
Endoscopy
Ambulatory pH monitoring
Combined Impedance-pH testing
Esophageal manometry
Acid suppression therapy.
Endoscopy
Insensitive- EE only in 5-10% of cases¹.
Highly specific
Costly
Invasive
Not likely to change management
Can help identify structural
abnormalities associated w GERD,
stricture, Schatzki’s ring, hiatal hernia
1. Cherian et al, Dis Esophagus 1995; 8:129
Ambulatory pH monitoring
Using endoscopy, a probe is attached to the
distal esophagus to measure changes in pH
for 48 hours.
Can be done on or off PPIs.
Diary allows correlation between symptoms
and acid reflux.
Sensitive and specific
Can help rule out PPI resistance
Costly
Invasive- greater pt discomfort ( occ chest
pain)
Can miss up to 25% of cases of reflux-not
due to “acid”
Impedance-pH monitoring
Performed the same way as pH monitoring
but the probe has an added sensor for
impedance.
It detects any bolus that enters the esophagusacid, bile or other.
Increases the sensitivity of the probe
Same disadvantages as pH probe
Additionally, it is not readily available
The gold standard for diagnosis of GERDrelated NCCP.
Esophageal Manometry
A thin probe is inserted intranasally and
advanced into distal esophagus.
Measurements are recorded as the pt is
asked to swallow sips of water.
Goal is to rule out motility disorders of the
esophagus as cause for chest pain.
Not very sensitive but specific
Tensilon (Edrophonium) provocation can be
used to increase sensitivity but it decreases
the specificity by increasing the number of
false positives.
Poorly tolerated by most
patients/invasive/costly.
Acid suppression therapy
Also called the “PPI Test”
Empiric trial of double dose PPI
therapy for 1 to 8 weeks.
Readily available
Cheap
Noninvasive
Well tolerated with few if any side
effects.
Both diagnostic and therapeutic
advantages
Next Step
What should be done next?
Endoscopy
Ambulatory pH monitoring
Combined Impedance-pH testing
Esophageal Manometry
Acid suppression therapy.
The answer is…..
Empiric trial of High dose PPI
Two meta-analyses combining 14 studies have
validated the PPI test.¹
Sensitivity and specificity of 75-80%.
Positive predictive value of ~90%.
One study, using a decision analysis model,
found the “treat first” approach to be
better:²
11% more diagnostic accuracy
43% reduction in invasive procedures
$454 saving per patient as compared to proceeding with
endoscopy and pH monitoring.
1.
Numans et al. Ann Intern Med 2004; 140:518.
2.
Ofman et al. Am J Med 1999; 107:219.
Management
If the PPI test fails, then one should
proceed with endoscopy/pH
monitoring +/- impedance testing
depending on availability.
Should it be performed on PPI
therapy or not? It depends…..
Is
it GERD?
Is it PPI resistance? (up to 20%).¹
1. Leite et al. Am J Gastroenterol 1996; 91:1572
Management
If there is no evidence of GERD and the pt
continues to have chest pain, one can have
manometry testing performed to rule out
dysmotility OR one can try an empiric trial of
calcium channel blockers.
Reason: manometry is uncomfortable and has
a high false negative rate.
Finally if all the above fails, Esophageal
Hyperesthesia is the most likely cause.
Try low dose TCAs- Trazodone and
imipramine are most commonly used.
Summary
NCCP is a very common problem with
high cost to the healthcare system and
significant morbidity to the patient.
The most common cause of NCCP is
GERD.
An empiric trial of high dose PPI
therapy is the single most effective
approach to dealing with NCCP.