Non Cardiac Chest Pain

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Non Cardiac Chest Pain is a common problem in both primary care and hospital settings. This presentation provides a simplified approach to non cardiac chest pain. It uses a case study to cover the evaluation, differential diagnosis, investigations and management for this common medical problem.

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Non Cardiac Chest Pain

  1. 1. Non Cardiac Chest Pain Dr Jarrod Lee Consultant Gastroenterologist & Advanced Endoscopist Mt Elizabeth Novena Specialist Centre 1
  2. 2. Case Scenario 2
  3. 3. Clinical History • 35 year male • Complains of intermittent chest pain x 6 mth – Occurs 3-4 times per week, lasts 15-20 min – Squeezing in nature, can interrupt normal activities – More likely after meals, but not exclusive • No dysphagia, heartburn, regurgitation or other GI symptoms; no weight loss or alarm symptoms • No past medical history; no CVS risk factors • No relevant family history 3
  4. 4. Further Evaluation • • • • • Physical examination unremarkable CXR normal FBC, LFT, RP, TFT normal Exercise treadmill normal Seen by A&E previously – Given omeprazole 20mg BD – Mild improvement (10%) with medication • Now has run out of medication and presents for further evaluation 4
  5. 5. What is the Likely Diagnosis? A. Cardiac Pain B. Gastro Esophageal Reflux Disease (GERD) C. Oesophageal Motility Disorder D. Musculoskeletal Chest Pain E. Functional Pain 5
  6. 6. What Would You Do? A. Coronary angiogram B. Restart omeprazole, add antacid C. Trial of ‘stronger’ proton pump inhibitor (PPI) D. Gastroscopy E. Ambulatory pH monitoring 6
  7. 7. Non Cardiac Chest Pain 7
  8. 8. Non Cardiac Chest Pain (NCCP) • > 30% of patients undergoing coronary angiogram for angina like pain have normal cardiac findings • Imperative to exclude cardiac causes before pursuing non-cardiac causes • Chest pain is common in oesophageal disorders – 60-80% of patients with non cardiac chest pain have oesophageal abnormality – Of these, GERD is the most common – Difficult to differentiate cardiac from oesophageal pain 8
  9. 9. Gastro Esophageal Reflux Disease (GERD) • 25-60% of GERD patients report chest pain • 60% of NCCP patients will have abnormal ambulatory pH monitoring • Of these, 80% will have symptomatic improvement with twice daily PPI (vs 6% with placebo) • In patients with proven coronary artery disease and atypical chest pain – 67% had proven GERD by pH studies – Majority had marked symptom improvement with PPIs 9
  10. 10. Other Differential Diagnosis • Hypersensitive Oesophagus – Symptoms with normal episodes of reflux not felt by healthy volunteers or GERD patients – Normal endoscopy, normal ambulatory pH monitoring, positive symptom association or index • Functional Heartburn – Chest pain not related to reflux – Normal endoscopy, normal ambulatory pH monitoring, negative symptom association or index 10
  11. 11. Oesophageal Motility Disorders • Uncommon • Difficult to attribute due to considerable changes in definition and classification over last 30 years • Usually associated with dysphagia • Achalasia – Chest pain seen in 60% – Presenting symptom in 5% • Diffuse Esophageal Spasm (DES) – Latest definition: 1-2% prevalence in NCCP 11
  12. 12. Investigations 12
  13. 13. PPI Test for Non Cardiac Chest Pain • • • • • Give for at least 1 week at twice daily dosing Can be extended up to 2 months Sensitivity > 70%; specificity > 85% Cost effective 1st step To maximize accuracy, need to ensure that PPI is taken in correct fashion relative to meals • Night time chest pain may not be diagnosed as well 13
  14. 14. Ambulatory pH Monitoring • Can determine the following: – Presence of GERD – Correlation of symptoms with acid exposure • > 50% of patients with NCCP have increased oesophageal acid exposure • Combined pH – Impedence Monitoring – Role uncertain in NCCP – Can improve GERD diagnosis up to 90% – 30% of NERD have weakly acidic reflux 14
  15. 15. 15
  16. 16. Other Tests • Gastroscopy – Limited diagnostic yield in chest pain • Erosive esophagitis found in 20% of Caucasian • Less prevalent in Asians (<5%) – May consider prior to a trial of PPI • Manometry – Mostly normal in 70-75% – Mostly non specific abnormalities in the remainder • Up to 10% have Diffuse Esophageal Spasm • Up to 2% have Achalasia 16
  17. 17. 17
  18. 18. Treatment 18
  19. 19. Treatment • Lifestyle Measures • Optimize PPI treatment for GERD • Surgery in selected cases with proven acid reflux and strong symptom association • Specialized treatment for other oesophageal disorders 19
  20. 20. Lifestyle Measures • • • • • Weight loss if overweight or recent weight gain Avoid meals 2-3H before bedtime Elevate head of bed for nocturnal GERD Stop alcohol and tobacco, but no evidence Selectively eliminate foods that may trigger reflux: – Chocolate, caffeine, alcohol, acidic/ spicy/ fatty foods – No evidence 20
  21. 21. Optimizing PPI Therapy • Sub-optimal PPI therapy is the largest cause of ‘refractory’ GERD – Optimal dosing before meals seen only in 40-50% – 70% of primary care physicians in US recommend to take at bedtime • If partial response – Switch to BD dosing or different PPI – Provides symptom improvement in 20% – No clear advantage with either strategy • If still not responding, consider refer to specialist 21
  22. 22. Conclusion • Diagnosis of NCCP is challenging given large number of differential diagnosis • First goal is to exclude cardiac causes • GERD is the most common cause of NCCP • PPI test for GERD is good for initial evaluation • Consider ambulatory pH monitoring if PPI test negative • Consider gastroscopy or manometry if ambulatory pH monitoring negative 22
  23. 23. Thank You Questions? 23

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