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Persistent Non-Cardiac Chest Pain in Patients on PPI Therapy

Prevalence, Prescribing Patterns and Results of pH Testing at a Tertiary Referral Center

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Achem, Sami R. M.D.; Ferguson, Dawn D. M.D.; Hugl, Beate M.D.; Wolfsen, Herbert M.D.; Stark, Mark M.D.; Bouras, Ernest M.D.; Devault, Kenneth R. M.D.

American Journal of Gastroenterology: September 2005 - Volume 100 - Issue - p S38–S39
Supplement Abstracts Submitted for the 70th Annual Scientific Meeting of the American College of Gastroenterology: ESOPHAGUS
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Gastroenterology, Mayo Clinic, Jacksonville, FL and Department of Surgery, Mayo Clinic, Jacksonville, FL.

Purpose: Gastro-esophageal reflux (GERD) occurs in 22–66% of patients with non-cardiac chest pain (NCCP). Proton pump inhibitors (PPIs) are widely available and are commonly prescribed as initial empirical therapeutic strategy for NCCP. Little is known about the patients who continue to experience chest pain despite PPI therapy and whether pH testing may offer additional information in this population.

Aims: To determine the prevalence of PPI use, describe prescribing PPI practices, and evaluate the diagnostic utility of pH testing in patients with persistent NCCP.

Methods: We reviewed consecutive patients with recurrent chest pain that received a PPI trial prior to their referral to our institution over a 2-year span. We determined the type and number of PPI trials prior to their referral to our institution. The results of 24-hour pH testing were also examined. GERD was diagnosed by abnormal acid contact time on pH testing.

Results: During the study period 130 patients were evaluated for NCCP, mean age 56.9 (range 23–90 years); 34.5% male, 65.5% female. Prior to referral to our center, 80 (61.5%) of these patients had received a PPI trial. At least, 20 (25%) had received 2 PPI trials and 6 (7.5%) received at least three PPI trials. The most commonly prescribed PPI prior to referral was omeprazole in 41 (54.6%) cases; esomeprazole was used in 18 (24%). All patients were asked to have 24-hour ambulatory pH testing and 59/80 (73.7%) consented. pH results were categorized to patients ON or OFF PPI therapy. The results were grouped as follows:

Conclusions: In patients referred for evaluation of persistent chest pain to a tertiary center as many as half these patients have received a PPI trial and over 25% at least two different trials. pH testing in these patients indicates that persistent acid reflux occurs in only the minority (8%) of these patients. Failure to respond to PPI trials should prompt search for other non-acid related sources of chest pain.

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