LETTER
Unexplained Noncardiac Chest Pain
Frank P. Castrina, MD
15 April 1997 | Volume 126 Issue 8 | Page 663
TO THE EDITOR:
Recent articles by Rao and colleagues [1] and Frobert and colleagues [2] add to the extensive literature about the esophagus as a cause of chest pain in patients who do not have coronary artery disease. An equally important issue is the misdiagnosis of esophageal disease in patients with acute coronary syndromes.
A report based on 10 years of data from the PHICO insurance company (a medical malpractice carrier) involving myocardial infarction that was not diagnosed in the emergency department showed that a gastrointestinal diagnosis was made in 35% (24 of 64) of the claims [3]. A finding in some misdiagnosed cases was relief of symptoms with the "gastrointestinal cocktail."
Analysis of 349 missed myocardial infarction claims by the Physician Insurers Association of America (PIAA) also noted that the most common misdiagnosis in their cases (26%) was gastrointestinal [4]. The PIAA is composed of professional liability carriers who underwrite more than 95 000 physicians in the United States.
The cause of misdiagnosis of gastrointestinal disorders or relief of symptoms with the gastrointestinal cocktail in acute myocardial infarction is multifactorial. The percentage of patients with concomitant esophageal dysfunction and coronary artery disease may be as high as 50% [5]. Other factors include stress-induced hyperacidity, the intermittent nature of cardiac symptoms, and patient denial.
Does acute coronary ischemia induce esophageal dysfunction? Concepts of visceral hyperalgesia and the relation of esophageal acid to coronary artery flow were discussed by Rao and colleagues and Frobert and colleagues. A concoction composed of antacids, lidocaine, or anticholinergics may affect overlapping viscerosensory pathways in the esophagus and relieve ischemic pain.
Although esophageal disease is a common cause of chest pain in the absence of heart disease, it also continues to be the main misdiagnosis in acute coronary syndromes. Physicians need to be aware that the gastrointestinal cocktail is an unreliable diagnostic test for identifying the cause of acute chest pain.
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Author and Article Information
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PHICO, Mechanicsburg, PA 17055-0085
1. Rao SS, Gregersen H, Hayek B, Summers RW, Christensen J. Unexplained chest pain: the hypersensitive, hyperreactive, and poorly compliant esophagus. Ann Intern Med. 1996; 124:950-8.
2. Frobert O, Funch-Jensen P, Bagger JP. Diagnostic value of esophageal studies in patients with angina-like chest pain and normal coronary angiograms. Ann Intern Med. 1996; 124:959-69.
3. Pelberg AL. Missed myocardial infarction in the emergency room. Quality Assurance and Utilization Review. 1989; 4:39-42.
4. Acute myocardial infarction study. Washington, DC: Physician Insurers Association of America; 1996.
5. Singh S, Richter JE, Hewson EG, Sinclair JW, Hackshaw BT. The contribution of gastroesophageal reflux to chest pain in patients with coronary artery disease. Ann Intern Med. 1992; 117:824-30.
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