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Unexplained Noncardiac Chest Pain
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Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
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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.
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
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