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.

1. Non Cardiac Chest Pain
Dr Jarrod Lee
Consultant Gastroenterologist & Advanced Endoscopist
Mt Elizabeth Novena Specialist Centre
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2. Case Scenario
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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
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4. Further Evaluation
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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
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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
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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
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7. Non Cardiac Chest Pain
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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
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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
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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
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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
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12. Investigations
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13. PPI Test for Non Cardiac Chest Pain
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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
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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
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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
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18. Treatment
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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
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20. Lifestyle Measures
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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
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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
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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
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23. Thank
You
Questions?
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