Diagnostic value of esophageal studies in patients with angina-like chest pain and normal coronary angiograms

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 Hotter 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.