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Gastro-oesophageal reflux in patients with coronary artery disease: how common is it and does it matter?
A J Mehta1, J S de Caestecker, A J Camm
1Department of Medicine, St George's Hospital Medical School, London, UK.
Objective:
To investigate the influence of spontaneous gastro-oesophageal reflux (GOR) on symptoms and cardiac ischaemia in patients with coronary artery disease.
Design:
Simultaneous 24-h ambulatory oesophageal pH, 7-lead electrocardiographic (ECG) monitoring and symptom diary in patients taking their usual anti-anginal medication.
Setting:
Regional cardiothoracic unit and gastroenterology unit of a teaching hospital.
Subjects:
Twenty-four patients (20 males, 4 females, mean age 59 years) with post-myocardial infarction angina and angiographically proven coronary artery disease.
Main Outcome Measures:
Quantitation of acid gastro-oesophageal reflux (% total time pH < 4, number of reflux episodes, duration of reflux episodes), identification of ST segment elevation or depression of 1 mm or more on 24-h ECG recording and occurrence of chest pain ("heartburn' or "angina') within 5 min of GOR or ischaemic ST segment shift.
Results:
There were 568 episodes of GOR, 28 of which were symptomatic. Abnormal GOR (% total time pH < 4 greater than 7%) occurred in 9 (38%) of the patients; all reflux parameters were increased in nitrate users compared to non-users (P < 0.05). Ischaemic ST-segment shift was seen on 113 occasions. Of a total of 41 chest pain episodes, 20 were related to GOR ("angina' with 8, "heartburn' with 12), while 8 coincided with both GOR and ST depression together ("angina' in 5, "heartburn' in 3). In addition to these eight episodes, coincidence of ST depression with GOR occurred on another nine occasions (all asymptomatic).
Conclusion:
GOR is common in patients with coronary artery disease and may be increased by drug therapy; GOR may occasionally be associated with myocardial ischaemia, but this is uncommonly symptomatic; GOR-induced pain is sometimes mistaken for angina. These effects were uncommon overall, but frequent in a few individuals and should be considered in the evaluation of patients with persistent chest pain despite seemingly adequate antianginal treatment.