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Recent advances in noncardiac chest pain in Korea
Jeong Hwan Kim1, Poong-Lyul Rhee
1Department of Internal Medicine, Digestive Disease Center, Medical Immunology Center, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea.
Insights
Gastroesophageal reflux disease (GERD) is a common cause of noncardiac chest pain (NCCP). In Korea, typical reflux symptoms and a proton pump inhibitor trial aid GERD diagnosis, with long-term PPI therapy often needed.
Area of Science:
- Gastroenterology
- Internal Medicine
- Clinical Diagnostics
Background:
- Gastroesophageal reflux disease (GERD) is a leading cause of noncardiac chest pain (NCCP), affecting up to 60% in Western countries and 41% in Korea.
- Korean patients with NCCP often present with typical reflux symptoms like heartburn and acid regurgitation.
- Endoscopy is recommended for Korean patients over 40 with NCCP (without alarming features) due to higher regional prevalence of peptic ulcers and gastric cancers.
Purpose of the Study:
- To outline diagnostic and management strategies for GERD-related NCCP in the Korean population.
- To highlight differences in GERD presentation and diagnostic approaches between Korea and Western countries.
- To provide guidance on proton pump inhibitor (PPI) therapy duration and dosage for GERD in Korea.
Main Methods:
- Review of clinical presentation and diagnostic criteria for GERD-related NCCP.
- Analysis of the efficacy of proton pump inhibitor (PPI) trials for presumptive GERD diagnosis.
- Evaluation of treatment duration and dosage recommendations for PPIs in GERD management.
- Consideration of alternative treatments for non-GERD-related NCCP.
Main Results:
- Typical reflux symptoms are indicative of GERD in Korean NCCP patients.
- A PPI trial of at least 2 weeks is suggested for presumptive GERD diagnosis in primary care, considering potentially atypical Korean presentations.
- Long-term, high-dose PPI therapy (over 2 months) is often necessary for symptom relief in GERD-related NCCP.
- Pain modulators, particularly newer agents like serotonin-norepinephrine reuptake inhibitors, are suggested for non-GERD-related NCCP due to fewer side effects than traditional tricyclics.
Conclusions:
- GERD is a significant cause of NCCP in Korea, manageable with a PPI trial and appropriate long-term therapy.
- Diagnostic approaches in Korea require consideration of regional cancer prevalence and potentially atypical symptom presentation.
- Optimizing PPI therapy duration and dosage, and exploring novel pain modulators, are key for effective NCCP management.
Abstract:
Gastroesophageal reflux disease (GERD) is the most common cause of noncardiac chest pain (NCCP) and is present in up to 60% of patients with NCCP in Western countries. In Korea, after a reasonable cardiac evaluation, GERD is reported to underlie 41% of NCCP cases. Typical reflux symptoms are frequent in Korean patients suffering from NCCP. Therefore, a careful history of the predominant symptoms, including heartburn and acid regurgitation, is relatively indicative of the GERD diagnosis in Korea. In Korea, in contrast to Western countries, patients aged 40 years and over who have been diagnosed with NCCP but who are without alarming features should undergo endoscopy to exclude gastric cancer or peptic ulcers because of the higher prevalence of peptic ulcer disease and gastric cancers in the region. In a primary care setting, in the absence of any alarming symptoms, a symptomatic response to a trial of a proton pump inhibitor (PPI) is sufficient for the presumptive diagnosis of GERD. In addition, the optimal duration of a PPI test may be at least 2 weeks, as GERD symptoms tend to be less frequent or atypical in Korean patients than in patients from Western countries. In patients diagnosed with GERD-related NCCP, long-term therapy (more than 2 months) with double the standard dose of a PPI is required to alleviate symptoms. Esophageal dysmotility is relatively uncommon, and pain modulators seem to offer significant improvement of chest pain control in non-GERD-related NCCP. Most traditionally available tricyclics or heterocyclics have many undesirable effects. Therefore, newer drugs with fewer side effects (for example, the serotonin - norepinephrine reuptake inhibitors) may be needed.
