Practical Validation of the COuGH RefluX Score: A Multicenter Study in Patients From Hispano-America

Laryngopharyngeal reflux symptoms (LPS) are often attributed to gastroesophageal reflux disease (GERD), yet objective testing confirms GERD in only a small subset of patients. The COuGH RefluX score, previously validated in North American and Taiwanese populations, offers a non-invasive method to stratify GERD likelihood in patients with LPS. This study aimed to evaluate its performance in a real-world Hispano-American cohort.

We performed a multicenter, retrospective cohort study in 459 adult patients from seven Neurogastroenterology units in Spain and Latin America, referred for LPS between 2018 and 2024. All patients underwent endoscopy, high-resolution esophageal manometry, and 24-h pH or Ph-impedance monitoring. Two versions of the COuGH RefluX score-original (including endoscopy and manometry data) and practical (including only endoscopy data)-were calculated. GERD status was defined per Lyon 2.0 criteria.

Proven GERD was identified in 164 patients (36%). The original COuGH RefluX score showed an AUC of 0.706, with 89% sensitivity and 89% specificity. The practical version showed an AUC of 0.684, maintaining the same sensitivity and specificity (both 89%). Compared to the original COuGH RefluX score, the practical version misclassified 54 patients due to undetected hiatal hernia on endoscopy alone; among these, 15 patients initially classified as indeterminate were downgraded to low likelihood-4 with proven GERD and 11 with unproven GERD. A subset of 197 (43%) patients reported at least three cough episodes during reflux monitoring. Among those with strong symptom association (n = 18), 67% had a high COuGH RefluX score, suggestive of a high GERD likelihood.

The COuGH RefluX score effectively stratifies GERD probability in patients with LPS. It may also identify patients with significant symptom-reflux associations, guiding targeted testing and therapy. This pragmatic tool could improve resource allocation by reducing unnecessary invasive testing in low-risk patients.