Thoracic pain of esophageal origin. Assessment of 125 consecutive patients with resting angina and angiographically normal coronary arteries

BACKGROUND: The esophagus may be the origin of chest pain clinically indistinguishable from that of myocardial ischemia. Gastroesophageal reflux (GER) and esophageal motility disorders (EMDs) are the main causes of esophageal chest pain, and esophageal motility tests are important for an appropriate diagnosis. We studied 125 unselected patients with angiographically normal coronary arteries presenting with atypical (resting) angina which was shown not to be of cardiac origin. METHODS: Stationary esophageal manometry and 24-hour pH studies were performed in all patients, and 116 of them were submitted to edrophonium provocation test (Tensilon, 10 mg as IV bolus). RESULTS: Spastic EMDs were identified as an isolated abnormality in 23 patients (18%), whereas GER was documented in 70 patients (56%). Esophageal dysmotility at baseline manometry (n = 40), a positive edrophonium test (n = 19), abnormal acid reflux indices by 24-hour pH recording (n = 62), and association of chest pain with acid reflux during pH testing (n = 24) variably overlapped in many patients. The esophagus was directly blamed as the source of atypical angina in 33 patients (26%) who had induction of their usual chest pain by cholinergic stimulation and/or association of spontaneous pain events with acid reflux. CONCLUSIONS: Esophageal dysfunction in common in patients with atypical angina considered not to be of cardiac origin and contributes to patients' symptoms. Because they may detect treatable causes of chest pain such as GER or contribute to management by assessing the diagnosis of EMD, esophageal motility tests are indicated in many patients with noncardiac chest pain.