The most common explanation for recurring substernal chest pain following negative cardiac evaluation is GERD (Fang and Bjorkman, 2001). Approximately 15% of patients will have esophagitis at endoscopy and up to 40% of patients will have elevated acid exposure time during 24hour pH monitoring. The remaining large subset has no evidence of pathologic reflux. About one-third of these will have a significant association of symptoms with acid reflux events, but as a group, all subjects without pathologic reflux respond less well to antireflux therapy. Twenty-five to 50% of patients with no pathologic reflux will have a spastic motor disorder on manometry, the wide variation in prevalence relating to different thresholds in assigning these diagnoses. Although the therapeutic approach is similar for all patients without pathologic reflux, some options are restricted to those with spastic motor disorders. The treatment algorithm for this group is reflected in Figure 18-3.
Not all patients undergo ambulatory pH monitoring in the primary phase of investigation, making therapeutic trials with PPIs important in the initial aspects of management. A short term (1-week) trial of 40 mg of omeprazole in the morning and 20 mg at night (or an equivalent regimen with an alternative PPI) is sensitive to 80 to 85% of subjects with pathologic reflux. Because the results of therapeutic trials often are ambiguous, nearly all patients with unexplained chest pain will continue such therapy for the early management period. As for pain in presence of spastic motor disorders, TCAs play an important role in res cuing subjects who fail to respond to antireflux therapy alone. Twenty-four-hour pH monitoring may help direct the need to continue antireflux therapy concurrent with antidepressant trials.
Management is challenging for those who respond poorly to these initial approaches. A common error is failure to increase the TCA to a satisfactory dosage, and full psychiatric dosing is required in some subjects (Clouse, 1994). Intolerance to TCA can prompt a trial of a contemporary antidepressant (such as a selective serotonin reuptake inhibitor) in usual psychiatric dosing. The response with regard to chest pain reporting in general has been less satisfactory. I have used other pain modulating agents on occasion, including carbamazepine and gabapentin, but have reserved these medications for refractory and debilitating symptoms or for pain with sharp or lancinating characteristics. Calcium channel blockers also have been used with anecdotal success.
Nonpharmacologic approaches can be useful in unexplained chest pain, just as in other functional gastrointestinal disorders. Cognitive behavioral psychotherapy, deep muscle relaxation, biofeedback, and other stress reduction techniques, are beneficial for some patients. Transcutaneous electrical nerve stimulation, acupuncture, and other alternative approaches, have had anecdotal success, but the best advice is to learn to maximize the use of antidepressants, particularly TCAs, in this patient group.
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