noncardiac chest pain1.pdf

Noncardiac Chest Pain Ronnie Fass, MD and Toma?s Navarro-Rodriguez, MD, PhD Abstract: Noncardiac chest pain (NCCP) affects approximately 1 quarter of the adult population in the United States. The pathophysiology of the disorder remains to be fully elucidated. Identified underlying mechanisms for esophageal pain include gastroesophageal reflux disease (GERD), esophageal dysmoti- lity, and visceral hypersensitivity. Aggressive antireflux treat- ment has been the main therapeutic strategy for GERD-related NCCP. NCCP patients with or without spastic esophageal motor disorders are responsive to pain modulators. The value of botulinum toxin injection, endoscopic treatment for GERD, and antireflux surgery in alleviating NCCP symptoms is limited. Key Words: gastroesophageal reflux disease, noncardiac chest pain, nonspecific esophageal motility disorder, lower esophageal sphincter (J Clin Gastroenterol 2008;42:636–646) Noncardiac chest pain (NCCP) is defined as recurringangina-like retrosternal chest pain of noncardiac origin. A patient’s history and characteristics do not reliably distinguish between cardiac and esophageal causes of chest pain.1 This is compounded by the fact that patients with a history of coronary artery disease (CAD) may also experience chest pain of noncardiac origin. The heightened awareness about the potentially devastating ramifications of chest pain may drive patients to seek medical attention despite a negative cardiac workup.2 Furthermore, almost half of the NCCP patients are not convinced by their negative cardiac diagnosis, and reassurance alone has proved to be an ungratifying therapeutic strategy.3 Compared with patients having cardiac angina, those with NCCP are usually younger, less likely to have typical symptoms, and more likely to have a normal resting electrocardiogram.4 Additionally, levels of anxiety of NCCP patients seen in a rapid access chest pain clinic significantly exceeded those of patients with cardiac angina and remained abov