Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux and Chest Pain

Not all chest pain comes from the heart. In fact, quite a bit is caused by conditions that have nothing to do with heart disease. This article reviews developments in the area of noncardiac chest pain and focuses on the roles that the esophagus, acid reflux, microvascular angina and abnormal visceral (organ) sensitivity to pain play in this condition.

How Big of a Problem?

A cardiac catheterization is often done when heart disease, such as blocked coronary arteries, is suspected as the cause of chest pain that comes and goes. Normal or near-normal heart arteries are found in up to 30 percent of patients undergoing catheterization. Based on 1 million cardiac catheterizations performed each year, an estimated 300,000 new cases of noncardiac chest pain are identified in this country every year. This estimate is probably conservative, since many patients younger than 40 years of age do not undergo coronary angiography.

A Diagnostic Challenge

Patients with noncardiac chest pain represent a diagnostic challenge for physicians. Their chest pain is often indistinguishable from pain caused by heart disease. However, since any chest pain can signal a life-threatening condition, such as a heart attack, it's important for physicians to rule out heart disease as the cause. Once heart disease and other disorders are excluded, patients are often referred for further studies to a gastroenterologist, a specialist in diseases of the esophagus, stomach and intestines.

Gastroesophageal Reflux and Chest Pain

The most common cause of esophageal chest pain is gastroesophageal reflux or GERD. The best way to diagnose GERD in patients with noncardiac chest pain is with tests that measure acid levels (or the pH concentration) in the esophagus, or food pipe, over 24 hours. This data is used, along with patients' diaries that note the occurrences of chest pain, to determine whether excessive acid causes the pain.

Worldwide studies using 24-hour ambulatory esophageal pH (acid levels) tests show that between 22 and 66 percent of patients who have noncardiac chest pain suffer from GERD. Our studies have demonstrated that intensive anti-reflux therapy using acid-suppressing medications will reduce chest pain in most of these patients.

Heightened Sensitivity to Pain

The observation that many patients with chest pain have normal coronary arteries led several researchers to look for sources of chest pain that have nothing to do with the reduced blood flow caused by blocked heart arteries. Recent studies have shown that some patients with chest pain suffer from enhanced visceral sensitivity in the heart and esophagus. That means that muscles in those organs are more sensitive and quick to send pain signals to the brain. Researchers do not know why this occurs, and intensive research continues to seek an explanation.

Studies are being done to find medications to blunt the visceral hyperalgesia, or heightened pain sensitivity, in these organs. Medications that may be helpful include tricyclic antidepressants, which seem to ease chronic pain, and somatostatin analogs, such as octreotide. However, controlled studies must be done to assess the medications' effectiveness.