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Diagnosing Gastroenterological Causes of Noncardiac Chest Pain

Endoscopy and pH tests should be used to confirm GERD status to guide decisions on treatment with PPIs and the need for further diagnostic testing.

The evaluation of patients with noncardiac chest pain commonly focuses on gastroesophageal reflux disease (GERD) or esophageal dysmotility as possible etiologies. Although many caregivers frequently use empiric treatment with proton-pump inhibitor (PPI) therapy to diagnose GERD as the cause of noncardiac chest pain, it is unclear whether a positive response is definitive.

To investigate this issue, researchers conducted a systematic literature review and identified six randomized controlled trials that reported response of chest pain (with negative cardiac evaluation) to PPI therapy versus placebo. In five of the six trials, PPIs were taken twice daily. Objective evidence of GERD was defined by either abnormal pH monitoring or endoscopic evidence of esophagitis.

In all trials, PPI therapy for noncardiac chest pain was effective in the majority of patients who tested positive for GERD, with a mean therapeutic gain from PPIs versus placebo of 62% (range, 56%–85%); however, in patients who tested negative for GERD, the mean therapeutic gain from PPIs versus placebo was only 5% (range, 0%–17%). In a meta-analysis of findings from five trials that used the same threshold for treatment response (50% improvement in chest pain), positive test results for GERD predicted response to PPI therapy (pooled relative risk, 4.3; P<0.0001), and negative results for GERD predicted nonresponse (pooled RR, 0.4; P=0.0004). The presence of concomitant heartburn was a poor predictor of PPI response.

Comment: The authors recommend that for patients whose objective diagnostic tests are negative for GERD, clinicians should use endoscopy and pH monitoring to decide which patients might benefit from further testing to determine the underlying cause of noncardiac chest pain. Finally, these study findings support the use of diagnostic tests in patients who fail to respond satisfactorily to PPI therapy. The finding that concomitant heartburn was a poor predictor of response is novel.

— David A. Johnson, MD

Published in Journal Watch Gastroenterology December 22, 2011

Citation(s):

Kahrilas PJ et al. Response of unexplained chest pain to proton pump inhibitor treatment in patients with and without objective evidence of gastro-oesophageal reflux disease. Gut 2011 Nov; 60:1473.

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  H Einwächter, Munich, Germany, 27 Dec 2011 11:39 AM EST
  Specialty: Gastroenterology
  "The authors recommend that for patients whose objective diagnostic tests are negative for GERD, clinicians should use endoscopy and pH... [more]

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