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Approach to managing undiagnosed chest pain

Could gastroesophageal reflux disease be the cause?

Peter Unge, MD PhD
Gastroenterologist at Bollnäs Hospital in Karolinska Institutet in Stockholm, Sweden.

Lars Agréus, MD PhD
Family physician with an interest in population-based and primary health care gastroenterology at the Centre for Family Medicine at the Karolinska Institutet.

Björn W. Karlson, MD PhD
Cardiologist at AstraZeneca Research and Development in Mölndal, Sweden.

Staffan Nilsson, MD
General practitioner at Vikbolandets Primary Care Centre in Norrköping, Sweden, and is affiliated with the Department of General Practice and Primary Care at the University of Linköping

Correspondence to: Dr Nigel Flook, University Hospital Family Medicine Clinic, 1A1.11, 8440-112 St, Edmonton, AB T6G 2B7; telephone 780 433-4211; fax 780 407-1828; e-mail nflook{at}shaw.ca

OBJECTIVE To highlight gastroesophageal reflux disease as a commoncause of undiagnosed chest pain.

SOURCES OF INFORMATION Diagnostic considerations are based on information in peer-reviewed articles retrieved from MEDLINE. Studies had to be in English and involve at least 30 subjects. Population-based studies had to have a sample size of at least 300 and a response rate of at least 60%. Thirty-seven relevant articles were found.

MAIN MESSAGE Clinical management of patients presenting with diagnostically challenging chest pain starts with a careful search for coronary artery disease and other potentially life-threatening causes. Investigations must continue until the underlying disease is identified and symptoms have been effectively controlled. Ongoing symptoms of undiagnosed chest pain cause considerable suffering, impair quality of life, and add unnecessary costs to the health care system. In more than half the patients with undiagnosed chest pain, symptoms are caused by gastroesophageal disease. Empirical acid-suppressive therapy with a proton pump inhibitor can assist clinicians in identifying patients whose symptoms are acid-related.

CONCLUSION Many patients with undiagnosed chest pain can be managed in primary care, minimizing the need for referrals and costly investigations.

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