Clinical Citations: Using antireflux therapy to evaluate the cause of noncardiac chest pain

Among the many causes of noncardiac chest pain, gastroesophageal reflux disease (GERD) is the most common. The diagnosis of GERD can be confirmed with 24-hour esophageal pH monitoring, but this test is invasive and is often unavailable in the primary care setting. The results of a meta-analysis conducted by Wang and associates suggest an alternative diagnostic approach: a therapeutic trial of a proton pump inhibitor (PPI).

The meta-analysis included 6 randomized placebo-controlled studies that evaluated the accuracy of PPI therapy (omeprazole, lansoprazole, or rabeprazole) in diagnosing GERD in adults with noncardiac chest pain. The diagnosis was confirmed by 24-hour esophageal pH monitoring or endoscopy.

The overall sensitivity and specificity of the PPI trial were 80% and 74%, respectively. The corresponding figures for placebo were 19% and 77%. PPI had a higher discriminative power, with a diagnostic odds ratio of 19.35, compared with 0.61 for placebo.

The investigators concluded that the use of high-dose PPI therapy for 4 weeks is a reasonable approach to the initial evaluation of noncardiac chest pain in select patients, such as those who do not have alarming symptoms or cardiac abnormalities. If the patient's symptoms are reduced by more than 50%, PPI treatment should be continued.