Unexplained (noncardiac) chest pain: Article five in the series
Colonography, Computed Tomographic
Unexplained chest pain is a common problem in clinical practice. Even after coronary artery disease has been ruled out and the patient reassured of the non-life-threatening nature of his or her condition, morbidity and decreased quality of life persist, at considerable economic and social cost. Awareness of an esophageal etiology, present in more than 60% of these patients, can lead to improvement as well as reassurance. Gastroesophageal reflux can be diagnosed in up to 50% of cases and successfully treated. Up to 25% to 30% of patients will have an esophageal motility disorder, often with high-amplitude esophageal peristaltic contractions (nutcracker esophagus). In 20% to 30%, pain will be elicited by provocative agents, suggesting a hypersensitive (or irritable) esophagus. A systematic approach to diagnosis, using ambulatory pH monitoring and esophageal motility testing, as well as provocative tests, will allow the physician to develop a logical and successful treatment plan for this complex group of patients. This article reviews the epidemiology, differential diagnosis, and management of unexplained chest pain in patients with normal coronary arteries.