Noncardiac chest pain (NCCP)

What is NCCP?

NCCP is recurring sub sternal chest pain of noncardiac origin.  There is a high prevalence of NCCP in the community, with females more likely to have it. The pain may be described as squeezing or burning in nature and may radiate to the back, neck, arms, and jaws.  The source of pain is usually the oesophagus

Discuss the causes of NCCP?

GORD, oesophageal dysmotility

Discuss the diagnosis?

A cardiac evaluation should be undertaken if appropriate.
An OGD is usually requested. However, it is likely to be normal. It may pick up erosive oesophagitis in 10-15% cases. An empiric PPI trial is much more effective
24 hr pH study- PPI trial will provide the same answers
Manometry- only achalasia is treatable and a good history will reveal the diagnosis of achalasia so manometry does not add much to diagnosis.

Discuss the management?

  • A PPI trial may be appropriate if NCCP is suspected after excluding a cardiac cause. High dose PPI (omeprazole 60-80 mgs in day) is used as symptoms of pain may be induced by oesophageal exposure to small amount of acid. PPI will need to be continued long term if the patient responds (50% or more reduction in chest pain in 2 weeks). A dose reduction may be attempted after a few weeks.
  • Failed PPI trial- tricyclic antidepressants (amitriptyline 50mg/day or trazodone) may be used.
  • Calcium channel blockers (diltiazem, nifedepine etc) have limited efficacy.

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