Non-Cardiac Chest Pain

1. Non-Cardiac Chest Pain AlixLanoue, MD Gastroenterologist in private practice Hollywood, Florida

2. 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

3. 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

4. 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

5. 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.

6. 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.

7. Differential • Non-Ischemic Cardiovascular • Aortic Dissection • Myocarditis • Pericarditis • Chest Wall • Cervical disc disease • Costochondritis* • Fibrositis • Herpes Zoster( before rash) • Neuropathic pain • Rib fracture • Sternoclavicular arthritis • Pulmonary • Pleuritis • Pneumonia • Pulmonary embolus • Tension pneumothorax • Psychiatric • Affective disorders • Anxiety disorders • Somatoform disorders

8. Differential contGastrointestinal • Non-esophageal • Biliary • Peptic ulcer disease • pancreatitis • Esophageal • Reflux diseases • Esophageal spasm • Esophageal hypersensitivity • Pill esophagitis • HIV-AIDS diseases • Lye ingestion • Achalasia

9. 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

10. Next Step What should be done next? • Endoscopy • Ambulatory pH monitoring • Combined Impedance-pH testing • Esophageal manometry • Acid suppression therapy.

11. 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

12. 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”

13. 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 esophagus- acid, 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 GERD-related NCCP.

14. 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.

15. 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

16. Next Step What should be done next? • Endoscopy • Ambulatory pH monitoring • Combined Impedance-pH testing • Esophageal Manometry • Acid suppression therapy.

17. 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. • Numans et al. Ann Intern Med 2004; 140:518. • Ofman et al. Am J Med 1999; 107:219.

18. 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

19. 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.

20. 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.