Non-Cardiac Chest Pain

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					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.¹‫³׳‬
      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                      Pulmonary
       Aortic Dissection                   Pleuritis
                                            Pneumonia
       Myocarditis
                                            Pulmonary embolus
       Pericarditis
                                            Tension pneumothorax
   Chest Wall
       Cervical disc disease
                                        Psychiatric
       Costochondritis*
                                            Affective disorders
       Fibrositis                          Anxiety disorders
       Herpes Zoster( before               Somatoform disorders
        rash)
       Neuropathic pain
       Rib fracture
       Sternoclavicular arthritis
Differential cont
Gastrointestinal

   Non-                Esophageal
    esophageal            Reflux  diseases
     Biliary             Esophageal
     Pepticulcer          spasm
      disease             Esophageal
     pancreatitis         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 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.
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.

				
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