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Antacids and diagnosis in patients with atypical chest pain
  1. Stewart Teece, Clinical Research Fellow,
  2. Ian Crawford, Clinical Research Fellow,
  3. K Mackway-Jones
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; kevin.mackway-jones{at}man.ac.uk

    Abstract

    A short cut review was carried out to establish whether antacids can be used as a diagnostic test in atypical chest pain. Altogether 374 papers were found using the reported search, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

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    Report by Stewart Teece, Clinical Research Fellow Checked by Ian Crawford, Clinical Research Fellow

    Clinical scenario

    A 57 year old man presents with a one hour history of central chest pain the character of which he cannot describe. There is no radiation but there is mild sweating and subjective shortness of breath. He has a history of smoking, hypertension, angina, and a hiatus hernia; the pain came on after a curry. He has a normal ECG on admission and an unremarkable examination. You cannot decide whether this is cardiac or oesophageal in origin and wonder whether a single dose of antacid might relieve his pain and therefore clarify the diagnosis

    Three part question

    In [a patient with chest pain of uncertain aetiology] is [the use of antacids/alginates] useful for [differentiating between cardiac and gastro-oesophogeal causes]?

    Search strategy

    Medline 1966–12/02 using the OVID interface. [exp chest pain OR exp angina pectoris OR exp angina, unstable OR exp coronary disease OR exp myocardial infarction OR chest pain.af OR angina.af OR coronary.af OR myocardial.af OR cardiac.af OR myocard$.af] AND [exp alginates OR exp antacids OR algin$.af OR antacid.af OR antacids.af OR gaviscon.af OR algicon.af OR gastrocote.af OR peptac.af OR topal.af OR indigestion.af OR heartburn.af OR dyspepsia.af] LIMIT to human AND English language.

    Search outcome

    Altogether 374 papers were found only two of which directly addressed the three part question (table 2).

    Table 2

    Comment(s)

    Both studies are small, however in the Henderson paper if the 95% confidence intervals are calculated (81.5% to 100% typical, 9% to 30.2% atypical) there is a distinct difference between the two groups despite all the patients having normal ETTs and angiography. A further paper by Davies et al has shown that the instillation of acid into the stomach decreases the angina threshold on exercise testing. The above tests would suggest that reflux affects angina and vice versa. The vagus nerve has been suggested as the common link between the two.

    CLINICAL BOTTOM LINE

    Antacids are useful in the relief of pain that is clearly oesophageal in origin but the effect is insufficiently specific to be of value in aiding diagnosis.

    Report by Stewart Teece, Clinical Research Fellow Checked by Ian Crawford, Clinical Research Fellow

    References

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