Hospital-based studies have suggested that GERD, esophageal spasm, psychiatric disease (including panic attacks), and musculoskeletal pain explain many cases of NCCP. However, unrecognized coronary artery disease and microvascular angina (cardiac syndrome X)also explain an unknown proportion of cases in the general population.Current studies suggest that NCCP is common in the general population and significantly affects QOL, yet only a minority seeks medical attention.. only a minority seeks medical attention yet.}The epidemiology of NCCP requires further study in the general population and in those attending the Emergency Department.
Non-cardiac chest pain (NCCP) consists of recurrent angina-type pain unrelated to ischemic heart disease or other cardiac source after a reasonable workup. The most common esophageal cause of NCCP is gastro-esophageal reflux disease (GERD), followed by esophageal motor disorders and esophageal visceral hypersensitivity. Noxious triggers for NCCP include non-acidic and acidic reflux events, mechanical distension and muscle spasm, longitudinal smooth muscle contraction particularly.
Heartburn is the cardinal symptom of gastroesophageal reflux disease (GERD). GERD is a common condition with a prevalence of 10-30% in Western Europe and North America. GERD is commonly diagnosed based on symptoms without diagnostic testing. Symptom response to anti-reflux treatment is used to further cement the diagnosis of GERD prior to entertaining any invasive testing. Tools that are available for diagnosing GERD include the PPI test currently, barium esophagram, upper endoscopy, esophageal pH monitoring, and multichannel intraluminal impedance with pH sensor (MII-pH).Noncardiac chest pain (NCCP) affects approximately one quarter of the adult population in the United States.
Aggressive treatment with proton pump inhibitors has become the standard of care for GERD-related NCCP. Pain modulators such as tricyclics, trazodone, and selective serotonin reuptake inhibitors are considered the mainstay of therapy for non-GERD-related NCCP Other therapeutic modalities such as botulinum toxin injections and hypnotherapy have demonstrated promise in small clinical trials. Chest pain is one of the most common symptoms driving patients to a physician’s office or the hospital’s emergency department. In half of the cases approximately, chest pain is of cardiac origin, either ischemic cardiac or nonischemic cardiac disease.
We propose that low EWBP leads to hypoxia of the esophageal tissue, which may be a mechanism of esophageal pain in patients with NE. Fourteen normal subjects (mean age 51 yrs, 11 males) and 12 patients (mean age 53 year, 9 males) with NE and NCCP were investigated. The EWBP was measured continuously using a custom designed laser Doppler probe tethered to a Bravo capsule, which anchored it to the esophageal wall. The course and development of noncardiac chest pain are assumed to be influenced by interoceptive processes.
Furthermore, it should also be taken into consideration that the production of neuroactive factor classes other than VitD related compounds is also affected by UVR. From immunoregulatory molecules Aside, neuropeptides, neurotrophins, and neurotransmitters, the CRH-POMC-system (corticotropin-releasing hormone-Pro-opiomelanocortin-system) for example is strongly influenced and regulated by UVR [ 75 ]. supplementation (5,000 IU/day) [ 18 ].
Several recent meta-analyses reevaluated the value of the PPI test in patients with classic GERD-related symptoms and noncardiac chest pain. Although the results were conflicting, the PPI test remains a popular tool for determining the presence of GERD.
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In this subgroup of NCCP patients, pain modulators have been demonstrated to be the most efficacious therapeutic strategy. The role of provocative testing has diminished in the last decade due to poor sensitivity and the introduction of the PPIs.
GERD is the most common underlying mechanism for NCCP and thus should be excluded first when evaluating a patient with NCCP. Noncardiac chest pain (NCCP) is very prevalent in the community. Although mortality remains low, morbidity and the financial implications are high. Women, those of middle age especially, should be thoroughly investigated as per current guidelines for coronary artery disease before labeling their chest pain as NCCP. Gastroesophageal reflux disease is the most common cause of NCCP; however other esophageal pathology including esophageal hypersensitivity, neuromuscular disease and eosinophilic esophagitis may also cause NCCP.
In patients with persistent chest pain despite short-term PPIs trial the next step is to perform 24-h distal esophageal pH monitoring or 48-h wireless distal esophageal pH monitoring off PPI therapy to provide objective evidence whether acid reflux is present. After excluding acid reflux, the next step is to perform esophageal manometry to determine whether a major esophageal motility abnormality may be causing the chest pain such as achalasia, esophagogastric junction outflow obstruction, jackhammer esophagus, diffuse esophageal spasm, or absent peristalsis. After exclusion of acid reflux, eosinophilic esophagitis, or esophageal motility abnormality, the diagnosis of non-cardiac chest pain due to visceral hypersensitivity (functional chest pain) can be made. Treatment options of functional chest pain include theophylline, low-dose antidepressants (imipramine, trazodone, sertraline, or venlafaxine), or psychological interventions such as cognitive behavioral therapy or hypnotherapy. The epidemiology of NCCP is poorly described, and the available data are conflicting.
Identified underlying mechanisms for esophageal pain include gastroesophageal reflux disease (GERD), esophageal dysmotility, and esophageal hypersensitivity. Patient’s history and symptom characteristics do not reliably distinguish between cardiac and esophageal causes of chest pain. All patients presenting with chest pain should be evaluated by a cardiologist to rule out a cardiac cause first. Non-gastrointestinal causes should be screened by the primary care physician prior to referral to a gastroenterologist.
However, gastroesophageal reflux disease (GERD) has remained the most common esophageal cause of NCCP. The introduction of the proton pump inhibitor test, a highly sensitive and cost-effective diagnostic strategy, simplified our diagnostic approach toward patients with GERD-related NCCP. For patients with positive proton-pump-inhibitor test results, long-term treatment with antireflux medication is warranted. For patients with non-GERD-related NCCP, pain modulators remain the cornerstone of therapy.
It was investigated whether heartbeat perception was enhanced in patients suffering from noncardiac chest pain and to what degree it was associated with self-reported cognitive-perceptual features and chest pain characteristics. One important limitation of the MUVY pilot study was that the second assessment of mood and well-being was performed three days after the final UVR exposure. This may have limited our ability to detect potential acute effects of UV irradiation on psychometric measures in healthy young women without clear symptoms of depressed mood or impaired functioning. Notably, most study participants reported spontaneously feeling better after the UVR sessions (less fatigued, more relaxed). Another limitation was that Parathyroid hormone was not measured in this pilot study, but this will be assessed in the subsequent trial.
Patients from the South Texas Ambulatory Research Network (STARNET) presenting with a new complaint of chest pain were asked to participate in the study. Before seeing their physician, subjects completed the panic disorder section of the Structured Clinical Interview (SCID) of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised.
Chest pain of esophageal origin
Proton pump inhibitors are commonly used initially to manage NCCP, although patients who do not respond to this therapy require further investigation and differing treatment regimes. This article will focus on current knowledge regarding GI tract-related NCCP management strategies.