How Do We Determine The Cause Of My Chest Pain?
Suffering from chest pain, but your doctor says it is not your heart.
150,000 Americans each year have normal heart catheterization. Even more come to the Emergency room or are admitted for evaluation of their heart, when their chest pain is in fact not caused by any blockage of the arteries. The leading cause of this pain that can mimic a heart attack, is acid rising up into the chest. In many cases this is not associated with prominent heartburn. This condition is Gastroesophageal Reflux and may occur with or without a hiatal hernia. When heartburn is absent it can be very confusing to both patient and doctor! Up until recently, the only way to evaluate this problem was a trial of medicine, which may or may not answer the question:
Do I go to the Emergency Room when I have chest pain? Dr. Gutman offers a novel and easy diagnostic plan.
Before beginning an evaluation of Non-Cardiac Chest Pain, it is critical that one has had a thorough cardiac evaluation. This may include an electrocardiogram, an echocardiogram, and either a nuclear stress test or stress echo. CT of the heart with calcium scoring or CT Angiography has proven to be very valuable in non-invasively detecting coronary artery blockage long before stress testing. Chest X-Ray or CT scan of the chest are needed to assess for lung or pleural disease.
The leading cause of Non-Cardiac Chest Pain is Gastroesophageal Reflux disease. Sonogram may be important to assess for gallbladder disease. Endoscopy can detect serious damage to the esophagus such as erosions, esophagitis, and Barrett’s esophagus. The majority of patients with Non-Cardiac Chest Pain have a normal esophagus on endoscopy, even when symptoms are severe. More useful are esophageal acid testing, and esophageal manometry test of the motor function of the esophagus.
The Diagnosis is at the Heart (Burn) of the Matter
It is vital to establish the true cause of the chest pain, in order to avoid the fear of recurring chest pain and avoid emergency room visits. The confidence of a clear diagnosis is actually more important than the treatment. Measuring the exposure of the esophagus to acid may lead to relief of the burning question: Am I having a heart attack? A clear diagnosis, allows for improved treatment, and allows confidence as to what is wrong.
The PPI Test
Every patient requires individualized diagnosis and treatment. The following recommendations offer the opportunity for you to knowledgeably discuss your management with your physician. One approach begins with the PPI test. A Proton Pump Inhibitor (PPI) is a very potent blocker of stomach acid. Given twice daily before eating, a PPI can nearly eliminate acid exposure in most people. Once a day dosing may be adequate for patients with heartburn, but generally not enough for chest pain, cough, asthma, etc. Your doctor may prescribe a PPI twice daily for 2 to 4 weeks and then reevaluate whether your symptoms are significantly improved. Patients who respond substantially may be kept on this dose for 3 months before trying to reduce the dose to once daily. Patients who do not convincingly respond should have esophageal pH testing. The PPI test is attractive because of its symplicity when it is effective, but suffers from the lack of a clearly established diagnosis before treatment is given for a significant length of time. That may lead to further emergency evaluations.
BRAVO Esophageal Acid pH Testing
BRAVO Wireless pH testing is an easy, reliable and insightful test for the evaluation of Non-Cardiac Chest Pain, after appropriate cardiology evaluation. Click here to learn more about BRAVO pH testing.Photo By: Kevin Dooley