Noncardiac Chest Pain–Treatment Approaches

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Treatment of noncardiac chest pain is often difficult because of the heterogeneous nature of the disorder. This condition can stem from gastroesophageal reflux, visceral hyperalgesia, esophageal motility disorders, psychiatric dysfunction, abnormal biomechanical properties of the esophageal wall, sustained esophageal contractions, abnormal cerebral processing of visceral stimulation, or disrupted autonomic activity. For a treatment to be successful, diagnosis of the underlying cause is essential. This article examines three decades of studies from around the world. It concludes that new research into additional mechanisms involved in visceral pain appears promising; but that future studies using improved selective adenosine receptor antagonists and other therapeutic interventions are needed.

Section snippets

Gastroesophageal reflux

GER is the most common cause of NCCP, and the best studied.12 The benefits of acid inhibition in NCCP have been demonstrated during short- (1 day–2 weeks) and long-term (6–8 weeks) trials. Tables 1 and 213, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 summarize the studies that have examined the impact of acid-inhibitory therapy in NCCP. These trials underscore the favorable effect of acid suppression in NCCP. Table 1 shows that for long-term therapy, only two studies were double blind and

Visceral hyperalgesia

Patients with NCCP show a heightened sensitivity to a variety of experimental esophageal stimuli such as pharmacologic provocation with cholinergic agonists, hydrochloric acid, and intraesophageal balloon distension.31 Studies have shown that 60% of patients with NCCP have an increased perception to esophageal distension, a phenomenon observed in only 20% of healthy controls.32 This increased reactivity has been termed visceral hyperalgesia and has also been described in subjects with irritable

Psychiatric disorders

Psychiatric conditions are common in NCCP. Several studies have noted a variable prevalence of panic disorders (24%–70%),40, 41, 42 anxiety (33%–50%),43, 44, 45 and major depression (11%–22%).46, 47 Management of these patients is difficult because physicians may not critically screen for these conditions. Treatment is further complicated by the patient's unwillingness to accept their psychiatric comorbidity and the lack of timely referral. The treatment may also be hampered by insufficient

Hypnotherapy

A recent study examined the effects of hypnotherapy in NCCP. During a small trial, 28 patients were assigned to receive hypnotherapy (12 sessions) or supportive therapy plus placebo medication for a 17-week period. The hypnotherapy group experienced significantly more chest pain reduction (global and intensity, but not frequency). Hypnotherapy did not affect anxiety or depression scores.64

Biofeedback

Biofeedback has been used in a small trial of 70 patients with a variety of functional disorders, including

Esophageal motility disorder

Esophageal motility disorders such as diffuse esophageal spasm (DES), nutcracker esophagus, and hypertensive lower-esophageal sphincter may be found in 28% to 30% of patients with NCCP.73, 74 Although it is not clear whether these motility disorders are the cause of NCCP or an epiphenomenon,75, 76 several pharmacologic trials aimed at reducing the abnormal esophageal motility in these patients have produced mixed results.77 Unfortunately, most of these trials have considerable flaws including

Recent pharmacologic developments

Treatment of NCCP remains difficult. The multi-factorial nature of the disorder and the insufficient understanding of the putative sensory mechanism (s) are some of the factors challenging us in finding an ideal therapeutic modality. Recent studies suggest that adenosine plays a role in esophageal sensory processing.118 Infusion of adenosine induces chest pain in patients with chest pain and coronary artery disease as well as in healthy controls and in patients with NCCP (without triggering

Summary

Treatment of NCCP remains difficult. In great part, this is due to the heterogeneous nature of the disorder. Available information indicates that GER is a very common problem in these patients and that PPI therapy is effective in reducing chest pain for the majority of patients with GER-related NCCP. Furthermore, a short trial of high-dose PPI may help identify those patients with GER-related NCCP.

On the other hand, the widespread use of PPI therapy has led to the recognition of a group of

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