EVALUATION OF THE PATIENT WITH NONCARDIAC CHEST PAIN: IS GASTROESOPHAGEAL REFLUX DISEASE OR AN ESOPHAGEAL MOTILITY DISORDER THE CAUSE?

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PRIMARY CARE FOCUS - EVALUATION OF THE PATIENT WITH NONCARDIAC CHEST PAIN:

IS GASTROESOPHAGEAL REFLUX DISEASE OR AN ESOPHAGEAL MOTILITY DISORDER THE

CAUSE?

Ronnie Fass, MD, and F. Winters, MD, discuss the challenges in

diagnosis and management that present to the treating physician in this

clinical setting.

Medscape Gastroenterology 3(6), 2001

http://primarycare.medscape.com/45165.rhtml?srcmp=pc-111601

" Chest pain is common, and up to 25% of the general population experiences

it in some form during their lifetime. However, of the ambulatory

population presenting with chest pain, only 11% to 34% are found to have a

cardiac cause. Of those patients who undergo coronary angiography annually,

about 30% have a normal test. In many other patients, cardiac cause is

excluded by noninvasive modalities.

" Symptoms of NCCP are often described as squeezing, burning substernal

chest pain that may radiate to the back, neck, arms, and jaws. Given the

overlap in symptoms between cardiac and noncardiac chest pain and the

seriousness of missing (failing to diagnose) heart disease, all patients

who present with chest pain should essentially undergo a cardiac work-up

prior to being referred to a gastroenterologist. Currently, there are no

symptom-based clues that are highly sensitive and specific for noncardiac

vs cardiac cause. Furthermore, patients with NCCP may respond to

administration of nitrates or calcium channel blockers. However, young

patients who lack family and personal history of cardiac disease are less

likely to have cardiac-related chest pain.

" Although the impact of chest pain on quality of life of patients with NCCP

has not been fully evaluated, it is likely to match other functional

gastrointestinal disorders, such as irritable bowel syndrome, in this

regard. Lack of reassurance is a strong motivating factor for these

patients to continue to seek medical attention. The seeking of such

reassurance leads to frequent visits to the same physician or multiple

physicians. Additionally, repeated emergency department visits,

hospitalizations, and testing are not uncommon. "