Figure 1. The heart and the esophagus are located in the chest in close proximity and also share same sensory nerves.
A variety of names have also been used in describing patients with NCCP. You may hear your doctor or other health care professional call it: “atypical chest pain, chest pain of undetermined origin, unexplained chest pain, functional chest pain, soldier’s heart, irritable heart, sensitive heart, neurocirculatory asthenia, DaCosta’s syndrome, and chest pain with normal coronary angiograms”.
Therefore, patients having chest pain who have had a negative cardiac evaluation are frequently referred to gastroenterologists (digestive disease specialists) to evaluate the esophagus as source of their chest pain.
NCCP is a common disorder with esophageal causes (described above) and nonesophageal related causes.
Non-esophageal sources that can cause NCCP include: Musculo-skeletal conditions of the chest wall or spine, pulmonary (lung) disorders, pleural illness (the layers of tissue that cover the lungs), pericardial conditions (the layer of tissue that protects the heart) and even digestive disorders such as ulcers, gallbladder, pancreatic diseases and rarely tumors (particularly in patients past age 50).
Some of patients with NCCP have also been found to suffer from stress that leads to disturbances such as depression, anxiety or panic disorder. It is unclear whether the stress disorder came first or the chest pain led to the appearance of an emotional disorder. Treatment of these conditions is an important component of treating chest pain.
Patients suffering from chest pain must have thorough cardiac evaluations to ensure they do not have heart disease prior to being labeled as having NCCP. In addition, a variety of other disorders described above, both esophageal and non-esophageal must also be considered since specific treatment for these disorders are available.
Patients may be treated as if the NCCP was a result of having GERD:
Once cardiac and other life-threatening conditions have been excluded and, based on the notion that the most common cause of NCCP is GERD a treatment trial is frequently considered.
Patients are often prescribed a proton pump inhibitor (PPI) also called a PPI trial. They must be taken at least 30-60 minutes before breakfast. It has been shown that this approach produces an approximately 80% response rate for patients with GERD-related NCCP. Some patients may also be given in addition to a PPI trial a medication called H2 Receptor antagonist (there are four types commercially available: Ranitidine, Famotidine, Nizatidine and Cimetidine, ) before bed, if symptoms occur at night or if the physician feels this course of therapy would be beneficial. This latter approach, however, has not been formally tested in scientific trials.
If the patient responds, the treatment can be continued for at least 8 weeks at a reduced dose such as Omeprazole (or equivalent) 20 mg twice daily about 40 min prior to meals. Other PPI’s can be also employed and include (Esomeprazole, Lansoprazole, Rabeprazole, Pantoprazole)
For patients not responding to a PPI GERD is the unlikely source of pain:
For these patients, other medications are available. These medications are felt to produce their favorable effect by reducing pain transmission from the esophagus to the brain. The medications often used are low doses and are from the class of drugs known as tricyclic antidepressants (TCAs), and not used at the high doses employed for the treatment of depression.
Commonly used agents are amitriptyline, nortriptyline, desipramine, imipramine and trazodone. The two most commonly used agents are imipramine and trazodone. While for the most part they are safe, side effects may include sleepiness, dry mouth, blurred vision and urinary retention. Trazodone can also cause a sustained erection (called priapism), which is considered a medical emergency. Other categories of antidepressants – such as “serotonin receptor uptake antagonist” or SSRI” – can be tried if TCA are not tolerated because of side effects. Two recent reports suggest that the SSRI Sertraline may also have a beneficial effect in the treatment of NCCP. This medicine was found to be more effective than placebo (a sugar pill or an inert substance) in the treatment of NCCP. New studies are also been done to explore other pain medications such as other SSRI’s like citalopram. For patients not responding to either acid inhibition trial or TCA or other antidepressants, esophageal motility testing (a study done to evaluate the muscle contractions of the swallowing pipe) may be done to look for other uncommon causes of chest pain such as achalasia. This is particularly important since achalasia is a treatable disorder.
A number of studies continue to be done to better understand the mechanism(s) of pain in NCCP. Furthermore, new treatment agents are being investigated. A recent study suggested that receptors in the esophagus such as the so called adenosine receptors that may account for visceral pain in NCCP. Using a medication that acts on these receptors (Theophilline) a group of investigators showed it may be effective for the treatment of NCCP. However, side effects of this particular agent may limit its use. Thus, in the future newer medications that act on these adenosine receptors but that have a better margin of safety may provide new opportunities for the treatment of this challenging condition.
Management of stress:
If patients do not respond to the above approach or they suffer from depression, anxiety, and/or panic disorder, they should be referred for appropriate psychiatric consultation and treatment.
Sami R. Achem, MD, FACP, FACG, AGAF, Mayo College of Medicine, Jacksonville, FL – Published February 2009.