Treatment of non-cardiac chest pain

Treatment of NCCP remains a difficult problem due to the heterogeneous nature of the disorder. GER is the best studied condition contributing to NCCP. Pharmacological trials of acid inhibition show a robust response rate for patients with NCCP-related GER. More rigorously executed studies are needed to understand the role of endoscopic therapies (if any) and surgery in patients with NCCP and coexisting GER. For patients with spastic disorders without GER, most therapeutic trials involve small, uncontrolled studies with variable outcome. Although a number of therapeutic options have been used to treat spastic dysmotility in these patients, no one agent has emerged as the drug of choice. Botox is a promising agent for the treatment of selected patients due to its rapid beneficial effect and relative simplicity (though invasive) of administration. However, placebo-controlled trials are lacking to validate its efficacy. NO donors and phosphodiesterase inhibitors are attractive compounds that warrant further testing since they seem to influence the intimate mechanism involved in the pathogenesis of DES (simultaneous contractions). Two TCA (imipramine and trazondone) remain valuable drugs in NCCP since small, randomized, placebo-controlled trials support their beneficial effect. The role of serotonin and the newly reported adenosine receptor pathway opens another opportunity for further research to better understand the neurotransmitters involved in the genesis of visceral chest pain. Finally, the high prevalence of psychiatric disorders in patients with NCCP is concerning. It begs for a combined multidisciplinary approach to study the interaction between the esophagus and the brain and better define the role, timing, and forms of psychological intervention in these patients. © 2008 Mosby, Inc. All rights reserved.