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Diagnostic Value of Esophageal Studies in Patients with Angina-like Chest Pain and Normal Coronary Angiograms

Ole Frobert, MD; Peter Funch-Jensen, MD, DSci; and Jens Peder Bagger, MD, DSci
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From the University of Aarhus, Aarhus, Denmark, and the University of Copenhagen, Copenhagen, Denmark. Grant Support: By Direktor Jacob Madsens & Hustru Olga Madsens Fond, the Gastroenterological Research Foundation of Eli Lilly, Fonden til Laegevidenskabens Fremme, the Institute of Experimental Clinical Research (University of Aarhus), Kirsten Anthonius's Mindelegat, Mogens Andreassens Fodselsdagslegat, Mogens Svarre Mogensens Fond, The Danish Heart Foundation, and a travel grant from Nycomed DAK. Acknowledgments: The authors thank Morten Frydenberg for statistical assistance and Jette Absalonsen, Inge Buschmann Nielsen, and Gertrud Naess-Schmidt for conducting and analyzing the Holter electrocardiographic recordings. Requests for Reprints: Ole Frobert, MD, Department of Cardiology, Skejby Hospital, University Hospital Aarhus, DK-8200 Aarhus N, Denmark. Current Author Addresses: Dr. Frobert: Department of Cardiology, Skejby Hospital, University Hospital Aarhus, DK-8200 Aarhus N, Denmark.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1996;124(11):959-969. doi:10.7326/0003-4819-124-11-199606010-00003
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Objective: To study 1) variations in esophageal motility and pH values and 2) electrocardiographic ST-segment changes in patients with angina-like chest pain but normal coronary angiograms.

Design: Cross-sectional study.

Setting: Tertiary cardiologic referral center.

Patients: 63 consecutive patients referred to the study center over a 3-year period and 22 healthy controls. Patients were grouped according to the results of exercise electrocardiography: normal response to exercise (n = 28) and ischemic response to exercise (n = 35).

Measurements: 1] 24-hour three-channel esophageal manometry and two-channel pH monitoring, 2) provocation testing with intravenous edrophonium chloride and esophageal acid perfusion, and 3) Holter electrocardiography conducted during the first two tests. In conventional time-weighted analyses, values during periods of pain and the 2 minutes before pain developed were compared with baseline values.

Results: Regardless of the outcome of exercise testing, no differences were seen in 24-hour esophageal variables between patients and controls. Forty-six patients had a total of 248 spontaneous episodes of chest pain. Only minor differences were seen between baseline and the prepain and pain periods. Edrophonium chloride provocation and acid perfusion caused chest pain in 9 patients (14%) and 10 patients (16%), respectively. Esophageal monitoring variables did not differ between patients with a positive response to one or both provocation tests (n = 16 [25%]) and controls and did not change between baseline and the prepain or pain periods. Forty-eight ST-segment depressions were recorded on Holter monitoring in 16 patients (25%), but these depressions were associated with one prepain period and four pain periods. No ST-segment changes were seen during esophageal provocation testing.

Conclusions: The rationale for routine esophageal investigations in this patient group is questionable.


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Figure 1.
Diagram of the study design.

ECG equals electrocardiogram.

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Figure 2.
Top.Bottom.black circlesrPwhite circlesrP

Diurnal variation in the percentage of the total number of episodes of chest pain (white bars) and of reflux (black bars) measured 5 cm above the lower-esophageal sphincter in 49 patients with angina-like chest pain, normal coronary angiograms, and complete 24-hour esophageal recordings. Also shown is the percentage of the total number of reflux episodes measured 5 cm above the lower-esophageal sphincter in 22 healthy controls (diagonally striped bars). Results were pooled for 2-hour intervals throughout the day. Scatter plots of pain episodes (number of pain episodes occurring in a 2-hour period expressed as a percentage of the total number of episodes). Pain episodes are shown in relation to the percentage of reflux episodes in patients ( ) ( = 0.83; < 0.001) and the number of reflux episodes in healthy controls ( ) ( = 0.85; < 0.001). The number of reflux episodes is expressed as the number of episodes occurring during a 2-hour period as a percentage of the total number of episodes in each group.

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