Review article: the current treatment of non‐cardiac chest pain

George, Nina; Abdallah, Jason; Maradey–Romero, Carla; Gerson, Lauren B.; Fass, Ronnie

doi:10.1111/apt.13458

Cited by 55 publications

(36 citation statements)

References 70 publications

(185 reference statements)

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“…Trials of empiric proton pump inhibitors have been recommended for concurrent diagnosis and treatment of GERD in patients with chest pain inconsistent with cardiac disease, 25,75–78 as GERD is a significant contributor in many cases. 78 From a psychopharma-cological standpoint, a recent meta-analysis of trials evaluating selective serotonin reuptake inhibitors (SSRIs) for the treatment of NCCP concluded that SSRIs were not superior to a placebo in improving symptoms of chest pain, suggesting that psychopharmacology alone is unlikely to be a sufficient management approach for NCCP. 79 Notably, 3 of 4 studies included in the meta-analysis excluded patients with comorbid psychiatric disease; as a result, this meta-analysis does not speak to the efficacy of SSRIs in patients with NCCP who have comorbid SSRI-responsive psychiatric conditions (e.g., MDD).…”

Section: Interventions To Treat Nccpmentioning

confidence: 99%

Non-cardiac Chest Pain: A Review for the Consultation-Liaison Psychiatrist

et al. 2017

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Background Patients presenting with chest pain to general practice or emergency providers represent a unique challenge, as the differential is broad and varies widely in acuity. Importantly, most cases of chest pain in both acute and general practice settings are ultimately found to be non-cardiac in origin, and a substantial proportion of patients experiencing non-cardiac chest pain (NCCP) suffer significant disability. In light of emerging evidence that mental health providers can serve a key role in the care of patients with NCCP, knowledge of the differential diagnosis, psychiatric co-morbidities, and therapeutic techniques for NCCP would be of great use to both consultation-liaison (C-L) psychiatrists and other mental health providers. Methods We reviewed prior published work on (1) the appropriate medical workup of the acute presentation of chest pain, (2) the relevant medical and psychiatric differential diagnosis for chest pain determined to be non-cardiac in origin, (3) the management of related conditions in psychosomatic medicine, and (4) management strategies for patients with NCCP. Results We identified key differential diagnostic and therapeutic considerations for psychosomatic medicine providers in 3 different clinical contexts: acute care in the emergency department, inpatient C-L psychiatry, and outpatient C-L psychiatry. We also identified several gaps in the literature surrounding the short-term and long-term management of NCCP in patients with psychiatric etiologies or co-morbid psychiatric conditions. Conclusions Though some approaches to the care of patients with NCCP have been developed, more work is needed to determine the most effective management techniques for this unique and high-morbidity population.

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Section: Interventions To Treat Nccpmentioning

confidence: 99%

Non-cardiac Chest Pain: A Review for the Consultation-Liaison Psychiatrist

et al. 2017

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“…However, treatment options and therapeutic results in patients with NCCP and hypercontractile esophageal motility disorders remain disappointing so far. Medical treatment, endoscopic pneumatic dilation of cardia or tubular esophagus, injection of botulinum toxin into the lower esophageal sphincter or esophageal body, and laparoscopic cardiomyotomy are of limited effect [6]. In this line, surgical myotomy is limited by the required combined abdominal and thoracic approach to reach all hypercontractile segments of the tubular esophagus sufficiently.…”

Section: Introductionmentioning

confidence: 99%

Peroral endoscopic myotomy (POEM) is effective in treatment of noncardiac chest pain caused by hypercontractile esophageal motility disorders: results of the POEM-HYPE-Study

et al. 2018

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Background Noncardiac chest pain (NCCP) is recurrent angina pectoris-like pain without evidence of coronary heart disease in conventional diagnostic evaluation. In gastroenterology, managing of patients with NCCP is ambiguous to detect gastroesophageal reflux and hypercontractile esophageal motility disorders. Recently, peroral endoscopic myotomy (POEM) was established as treatment option in achalasia. However, limited data exist on the effectivity of POEM in NCCP with hypercontractile esophageal motility disorders. Material and methods In this prospective study (POEM-HYPE), we evaluated 14 patients with NCCP and hypercontractile esophageal motility disorders (type III achalasia, n = 7; hypercontractile esophagus, n = 6; distal esophageal spasm, n = 1). All patients underwent standardized diagnostic work-up including esophagogastroduodenoscopy with esophageal biopsies, high-resolution esophageal manometry, and combined intraluminal impedance and pH testing before and 3 weeks after POEM. A standardized symptom questionnaire was disposed before POEM, 3 weeks after, and every 6 months after the POEM. Results After POEM, 12 patients showed significant symptom relief (pre-Eckardt score: 7.78 ± 1.47, 3 weeks post: 1.64 ± 1.44, 6 months: 2.0 ± 1.84 and 1.86 ± 1.89 after 15.0 ± 10.0 months post-intervention). High-resolution manometry showed significant reduction in integrated relaxation pressure (pre-POEM: 24.74 ± 18.9 mm Hg, post-POEM: 13.8 ± 16.5 mm Hg) and distal contractile integral (pre-POEM: 2880 ± 3700 mmHg*s*cm, post-POEM: 1109 ± 1042 mmHg*s*cm). One lesion of the submucosal tunnel occurred as a moderate adverse event and was handled endoscopically. The long-term clinical success rate was 85.7 %. No severe gastroesophageal reflux occurred after interventions. Two patients required secondary therapy with injection of botulinum toxin in the tubular esophagus and balloon dilation. Conclusion The results suggest that POEM is an effective and safe therapeutic option for patients with NCCP and hypercontractile esophageal motility disorders.

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“…Patients with NCCP might be referred to antireflux surgery after ruling out oesophageal motility disorders such as hypercontractile oesophagus and functional chest pain. 39 Although literature on GORD-related NCCP as the sole indication for surgical treatment is non-existent, fundoplication has been performed in this patient group. Improvement after surgical treatment is better in patients with a clear correlation between reflux events and symptoms, in patients who also display typical reflux symptoms such as heartburn and third when there is a satisfactory response to PPIs prior to the surgery.…”

Section: Clinical Presentation and Comorbiditiesmentioning

confidence: 99%

How to select patients for antireflux surgery? The ICARUS guidelines (international consensus regarding preoperative examinations and clinical characteristics assessment to select adult patients for antireflux surgery)

Pauwels

Boecxstaens

Andrews

et al. 2019

Gut

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ObjectiveAntireflux surgery can be proposed in patients with GORD, especially when proton pump inhibitor (PPI) use leads to incomplete symptom improvement. However, to date, international consensus guidelines on the clinical criteria and additional technical examinations used in patient selection for antireflux surgery are lacking. We aimed at generating key recommendations in the selection of patients for antireflux surgery.DesignWe included 35 international experts (gastroenterologists, surgeons and physiologists) in a Delphi process and developed 37 statements that were revised by the Consensus Group, to start the Delphi process. Three voting rounds followed where each statement was presented with the evidence summary. The panel indicated the degree of agreement for the statement. When 80% of the Consensus Group agreed (A+/A) with a statement, this was defined as consensus. All votes were mutually anonymous.ResultsPatients with heartburn with a satisfactory response to PPIs, patients with a hiatal hernia (HH), patients with oesophagitis Los Angeles (LA) grade B or higher and patients with Barrett’s oesophagus are good candidates for antireflux surgery. An endoscopy prior to antireflux surgery is mandatory and a barium swallow should be performed in patients with suspicion of a HH or short oesophagus. Oesophageal manometry is mandatory to rule out major motility disorders. Finally, oesophageal pH (±impedance) monitoring of PPI is mandatory to select patients for antireflux surgery, if endoscopy is negative for unequivocal reflux oesophagitis.ConclusionWith the ICARUS guidelines, we generated key recommendations for selection of patients for antireflux surgery.

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Review article: the current treatment of non‐cardiac chest pain

Cited by 55 publications

References 70 publications

Non-cardiac Chest Pain: A Review for the Consultation-Liaison Psychiatrist

Non-cardiac Chest Pain: A Review for the Consultation-Liaison Psychiatrist

Peroral endoscopic myotomy (POEM) is effective in treatment of noncardiac chest pain caused by hypercontractile esophageal motility disorders: results of the POEM-HYPE-Study

How to select patients for antireflux surgery? The ICARUS guidelines (international consensus regarding preoperative examinations and clinical characteristics assessment to select adult patients for antireflux surgery)

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