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Noncardiac Chest Pain and Proton Pump Inhibitors—Reply

Noncardiac Chest Pain and Proton Pump Inhibitors—Reply In reply We disagree with many of the concerns that Numans raised and would like to discuss the meta-analysis by him and his colleagues.1 Understanding the physiologic features of nonerosive reflux disease would have identified the limitation of the PPI test in patients with GERD that resulted in attenuated conclusions. In these trials, the PPI test is compared with a combination of 24-hour esophageal pH testing and upper endoscopy. As a result, patients excluded by the PPI test are those with functional heartburn (typical heartburn but normal endoscopy and 24-hour pH monitoring). However, as Numans et al1 have found, the sensitivity of the PPI test in GERD was relatively high, but the specificity was low. This is primarily because a subset of patients with functional heartburn responded to PPI therapy. Up to 50% of patients with functional heartburn respond to treatment with PPIs once a day,2 with an even better response to higher doses of PPIs.3 In fact, the meta-analysis by Numans et al1 provides support for the PPI test because of its capability of diagnosing functional heartburn that is responsive to antireflux medications. This was clearly not taken into consideration. Our study is highly relevant to primary care physicians.4 A recent survey showed 79.5% of patients with NCCP are treated by primary care physicians.5 Only 62.2% of the patients with chest pain are referred to a cardiologist. We have recognized in therapeutic studies of nonerosive reflux disease and atypical, extraesophageal manifestations of GERD that complete resolution of symptoms is clinically not practical. For patients with NCCP, 50% reduction in symptoms results in high satisfaction rate and marked improvement in quality of life and serves as a reasonable clinical end point. Thus, with respect to the limitations of the meta-analysis by Numans et al1 of the PPI test in patients with GERD, we encourage them to recognize the benefits of the PPI test in NCCP. We agree with Bobba and Arsura that many studies included a small number of patients. However, they used a crossover design, and there was no carryover effect. Unlike empirical therapy, the purpose of the therapeutic trial is to make the diagnosis of GERD in patients with NCCP by using PPIs. We are not sure how upper endoscopy or 24-hour esophageal pH monitoring, after a positive therapeutic trial result, would improve the management of patients with NCCP.4 The 24-hour pH monitoring was not performed to demonstrate an association between patient's chest pain and acid reflux events because a positive association between chest pain and acid reflux events is uncommon.6 The meta-analysis does not recommend performing 24-hour pH testing in all patients with NCCP. On the contrary, it supports the PPI test, which is cost-effective, primarily owing to the reduction in the use of invasive procedures such as pH testing.7 The purpose of the PPI test is to exclude patients with no GERD. Thus, The PPI test would have failed in patients with significant motility abnormalities without GERD. Correspondence: Dr Wong, Department of Medicine, University of Hong Kong, Pokfulam Road, Hong Kong (bcywong@hku.hk). References 1. Numans MELau JWit NJ et al. Short-term treatment with proton pump inhibitors as a diagnostic test for gastro esophageal reflux disease: a meta-analysis of diagnostic test characteristics. Ann Intern Med 2004; ((140)) 518- 527PubMedGoogle Scholar 2. Lind THavelund TCarlsson R et al. Heartburn without oesophagitis: efficacy of omeprazole therapy and features determining therapeutic response. Scand J Gastroenterol 1997;32974- 979PubMedGoogle ScholarCrossref 3. Watson RGTham TCJohnston BT et al. Double blind cross-over placebo controlled study of omeprazole in the treatment of patients with reflux symptoms and physiological levels of acid reflux—the “sensitive esophagus” Gut 1997;40587- 590PubMedGoogle Scholar 4. Wang WHHuang JQZheng GF et al. Is PPI testing an effective approach to diagnose gastroesophageal reflux disease in patients with noncardiac chest pain? a meta-analysis. Arch Intern Med 2005;1651222- 1228PubMedGoogle ScholarCrossref 5. Wong W-MBeeler JRisner-Adler S et al. Attitudes and referral patterns of primary care physician (PCP’s) when evaluating subjects with noncardiac chest pain (NCCP): a national survey. Dig Dis Sci 2005;50656- 661PubMedGoogle ScholarCrossref 6. Dekel RMartinez-Hawthorne SDGuillen RJFass R Evaluation of symptom index in identifying gastroesophageal reflux disease-related noncardiac chest pain. J Clin Gastroenterol 2004;3824- 29PubMedGoogle ScholarCrossref 7. Ofman JJGralnek IMUdani JFennerty MBFass R The cost-effectiveness of the omeprazole test in patients with noncardiac chest pain. Am J Med 1999;107219- 227PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Noncardiac Chest Pain and Proton Pump Inhibitors—Reply

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Publisher
American Medical Association
Copyright
Copyright © 2006 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.166.2.248-b
Publisher site
See Article on Publisher Site

Abstract

In reply We disagree with many of the concerns that Numans raised and would like to discuss the meta-analysis by him and his colleagues.1 Understanding the physiologic features of nonerosive reflux disease would have identified the limitation of the PPI test in patients with GERD that resulted in attenuated conclusions. In these trials, the PPI test is compared with a combination of 24-hour esophageal pH testing and upper endoscopy. As a result, patients excluded by the PPI test are those with functional heartburn (typical heartburn but normal endoscopy and 24-hour pH monitoring). However, as Numans et al1 have found, the sensitivity of the PPI test in GERD was relatively high, but the specificity was low. This is primarily because a subset of patients with functional heartburn responded to PPI therapy. Up to 50% of patients with functional heartburn respond to treatment with PPIs once a day,2 with an even better response to higher doses of PPIs.3 In fact, the meta-analysis by Numans et al1 provides support for the PPI test because of its capability of diagnosing functional heartburn that is responsive to antireflux medications. This was clearly not taken into consideration. Our study is highly relevant to primary care physicians.4 A recent survey showed 79.5% of patients with NCCP are treated by primary care physicians.5 Only 62.2% of the patients with chest pain are referred to a cardiologist. We have recognized in therapeutic studies of nonerosive reflux disease and atypical, extraesophageal manifestations of GERD that complete resolution of symptoms is clinically not practical. For patients with NCCP, 50% reduction in symptoms results in high satisfaction rate and marked improvement in quality of life and serves as a reasonable clinical end point. Thus, with respect to the limitations of the meta-analysis by Numans et al1 of the PPI test in patients with GERD, we encourage them to recognize the benefits of the PPI test in NCCP. We agree with Bobba and Arsura that many studies included a small number of patients. However, they used a crossover design, and there was no carryover effect. Unlike empirical therapy, the purpose of the therapeutic trial is to make the diagnosis of GERD in patients with NCCP by using PPIs. We are not sure how upper endoscopy or 24-hour esophageal pH monitoring, after a positive therapeutic trial result, would improve the management of patients with NCCP.4 The 24-hour pH monitoring was not performed to demonstrate an association between patient's chest pain and acid reflux events because a positive association between chest pain and acid reflux events is uncommon.6 The meta-analysis does not recommend performing 24-hour pH testing in all patients with NCCP. On the contrary, it supports the PPI test, which is cost-effective, primarily owing to the reduction in the use of invasive procedures such as pH testing.7 The purpose of the PPI test is to exclude patients with no GERD. Thus, The PPI test would have failed in patients with significant motility abnormalities without GERD. Correspondence: Dr Wong, Department of Medicine, University of Hong Kong, Pokfulam Road, Hong Kong (bcywong@hku.hk). References 1. Numans MELau JWit NJ et al. Short-term treatment with proton pump inhibitors as a diagnostic test for gastro esophageal reflux disease: a meta-analysis of diagnostic test characteristics. Ann Intern Med 2004; ((140)) 518- 527PubMedGoogle Scholar 2. Lind THavelund TCarlsson R et al. Heartburn without oesophagitis: efficacy of omeprazole therapy and features determining therapeutic response. Scand J Gastroenterol 1997;32974- 979PubMedGoogle ScholarCrossref 3. Watson RGTham TCJohnston BT et al. Double blind cross-over placebo controlled study of omeprazole in the treatment of patients with reflux symptoms and physiological levels of acid reflux—the “sensitive esophagus” Gut 1997;40587- 590PubMedGoogle Scholar 4. Wang WHHuang JQZheng GF et al. Is PPI testing an effective approach to diagnose gastroesophageal reflux disease in patients with noncardiac chest pain? a meta-analysis. Arch Intern Med 2005;1651222- 1228PubMedGoogle ScholarCrossref 5. Wong W-MBeeler JRisner-Adler S et al. Attitudes and referral patterns of primary care physician (PCP’s) when evaluating subjects with noncardiac chest pain (NCCP): a national survey. Dig Dis Sci 2005;50656- 661PubMedGoogle ScholarCrossref 6. Dekel RMartinez-Hawthorne SDGuillen RJFass R Evaluation of symptom index in identifying gastroesophageal reflux disease-related noncardiac chest pain. J Clin Gastroenterol 2004;3824- 29PubMedGoogle ScholarCrossref 7. Ofman JJGralnek IMUdani JFennerty MBFass R The cost-effectiveness of the omeprazole test in patients with noncardiac chest pain. Am J Med 1999;107219- 227PubMedGoogle ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jan 23, 2006

Keywords: chest pain, noncardiac,proton pump inhibitors

References