Chest pain: abnormal oesophageal pH and motility did not rule out coronary artery disease.

Clinical bottom line (level 4)

  1. Patients with intermittent chest pain who had no coronary artery disease were more likely to have chest pain for over a year, than patients with coronary artery disease.
  2. Patients with or without coronary artery disease were equally likely to have relief from nitrates.
  3. Gastroesophageal reflux or motility disorder was common in both patients with and without coronary artery disease.
  4. Ambulatory oesophageal pH and motility monitoring did not clearly distinguish patients with coronary artery disease from those without. Both types of patient were as likely to get chest pain during the recording.
Lux et al: Neurogastroenterology Mot. 1995; 7: 23-30
Expires March 2003

The study

Setting: university hospital, Germany

45 patients (aged range 32 to 76 years; mean 61, 58% male) with intermittent chest pain referred for investigation. 30 patients (63% female; aged 32 to 66; mean 55) with normal coronary arteries and 15 patients (20% female; aged 50 to 76; mean 67) with significant coronary artery stenosis

Excluded if
  • arterial hypertension


All drugs affecting motility, gastric acidity or pain perception were discontinued 24 hours before resting. No patient received omeprazole or H2 antagonists.
Independent unblinded reference standard, applied in all patients from a consecutive inappropriate spectrum.
Reference standard:
  • angiography and exercise test
Diagnostic test: ambulatory oesophageal pressure and pH monitoring for 24 hours. Patients recorded episodes of pain in a diary. Pain was considered to be due to gastro-oesophgeal causes if pH fell to < 4.0 within 2 minutes of onset of pain, during > 50% of episodes of pain.

The evidence


diagnostic test no coronary artery disease coronary artery disease LR+
(95% CI)		 LR-
(95% CI)
pain for longer than a year 19 0 infinity
(3.5 to infinity) 		0.37
(0.23 to 0.59)
pain relieved by nitrates 5 6 0.40
(0.15 to 1.1) 		1.4
(0.89 to 2.2)
chest pain during recording 14 7 1.0
(0.52 to 1.9) 		1.0
(0.56 to 1.8)
gastro-esophageal reflux or motility disorder 6 8 0.40
(0.16 to 0.90) 		1.7
(0.97 to 3.0)
pain related to gastro-esophageal reflux or motility disorder 10 4 1.3
(0.47 to 3.3) 		0.91
(0.61 to 1.4)
total 30 15

  • No differences were noted between the two groups in meal habits, episodes of heartburn, symptoms of functional dyspepsia, sleeping habits, alcohol intake, body weight, frequency of dysphagia and nicotine abuse, duration, quality and localisation of pain, and its relation to exertion.

Comments

  1. Oesophageal monitoring is commonly done in patients with chest pain and normal coronary arteries. This study suggests that oesophageal monitoring may add little to identifying the cause of chest pain in these patients.

Citation

  1. Lux G, Van Els J, The GS, et al: Ambulatory oesophageal pressure, pH and ECG recording in patients with normal and pathological coronary angiography and intermittent chest pain. Neurogastroenterology Mot. 1995; 7: 23-30
Search Terms: chest pain in Cochrane
Contributor: Chris Ball and Clare Wotton, Unknown Month 2000
Reviewer:

Clinical Question.
    Patient chest pain
    Intervention or Exposure oesophageal pH and motility
    Outcome diagnosis of coronary artery disease