Gastroesophageal reflux disease as a cause of chest pain

Patients with recurrent chest pain free of significant coronary artery disease account for 10% to 30% of patients undergoing coronary angiography. Recent studies suggest that gastroesophageal reflux disease may be very common in these patients. The cause of this chest pain seems to be related primarily to an acid-sensitive mucosa regardless of the presence of esophagitis. Unfortunately, a careful history will not distinguish chest pain arising from a cardiac versus an esophageal source. Therefore, all patients must undergo a thorough cardiac evaluation before assuming that acid reflux is the cause of their complaints. Initial gastroenterology evaluation will usually include upper GI endoscopy or barium studies, possibly with acid perfusion (Bernstein) testing, or both. However, the more sensitive and specific test for acid-related disease is prolonged esophageal pH monitoring. This study quantifies the amount of acid reflux but, more importantly, identifies the relationship between chest pain and acid reflux episodes. Patients should be studied in the outpatient setting with emphasis placed on performing activities that replicate their chest pain. Although we presume that acid-induced chest pain responds as well as heartburn to vigorous antireflux regimens, there are few studies to address this issue. Nevertheless, I have had great success in treating these patients with either high-dose H2 blockers or omeprazole therapy.