The Diagnosis and Management of Unexplained Chest Pain--Is Less.More?

Hookman, Perry; Barkin, Jamie S.; Johnson, David
August 1999
American Journal of Gastroenterology;Aug1999, Vol. 94 Issue 8, p2310
Academic Journal
This prospective study compared the incidence and types of esophageal motor abnormalities in 61 patients with chest pain and normal coronary angiograms that were felt not to be of cardiac origin, compared to 25 control patients with proven coronary artery disease (CAD) and angina pectoris. For the purposes of this study, typical chest pain satisfied at least two of the following criteria; reproducibility provoked by exercise; rest pain accounting for no more than 10% of pain episodes; and duration of pain 5 min or less. Although the paper was published in 1998, this study was performed between 1990 and 1991. It included a total of 1022 consecutive patients who underwent coronary angiography as part of the investigation of chest pain. Of these, 84 (8.2%) had completely normal angiograms and no evidence of coronary artery spasm. The authors further excluded patients with mitral valve prolapse, left ventricular hypertrophy, or abnormalities of resting or motion on echocardiography and those patients with previous myocardial infarction. This resulted in a final remaining study group of 61 patients, who were compared to 25 controls, all of whom had angina pectoris proven by significant obstructive coronary disease with >70% luminal diameter narrowing of at least one major epicardial artery. All patients underwent esophageal evaluation, which consisted of esophageal manometry, 24-h ambulatory pH monitoring, and an acid perfusion test. Another provocation test, edrophonium, was not performed in the proven CAD control group because this was not considered ethical. The authors found a high incidence of esophageal abnormalities in both groups consisting of the following: 1. Simultaneous contractions were more common (6.7% vs 0.8%) (p < 0.01) in the patients with normal coronary angiograms than in those with proven CAD. Sixteen percent of patients with normal coronary angiograms had diffuse spasm whereas no patients with CAD had diffuse spasm. This finding led to the authors' conclusion that esophageal spasm is indeed a potential cause of chest pain in patients with normal coronary angiograms. 2. The duration of peristaltic contractions was longer (2.9 vs 2.4 s) in patients with normal coronary angiograms versus those in the CAD group. 3. There were no differences in the amplitude of peristaltic contractions between the two groups, and none of the patients had nutcracker esophagus. 4. Twenty-one (34%) of patients in the normal coronary angiogram group had abnormal gastroesophageal reflux compared to five (20%) of patients with CAD. There was no significant difference between the groups as to the number of patients whose pain was temporally related to pH-monitored acidity. The authors also reported that the incidence of esophageal motor abnormalities and, in particular, the correlation of pH events with chest pain are just as common in patients with normal coronary angiograms as in patients with confirmed CAD. The authors stated that esophageal testing incriminated the esophagus as a source of chest pain in 44% of patients with normal angiograms and in 36% of patients with proven CAD. They concluded that all patients with unexplained chest pain after normal coronary angiography should be considered for esophageal testing, including standard manometric studies, provocative tests with acid perfusion test, and 24-h pH monitoring.


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