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.