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Operating on the premise that acid reflux can cause nonspecific chest pain, clinicians often prescribe proton-pump inhibitors (PPIs) for patients with unexplained chest pain. Industry-sponsored researchers assessed the efficacy of this intervention in 599 patients (mean age, 47) with at least 2 weeks of unexplained chest pain; all patients had negative exercise tolerance tests, no obvious cardiopulmonary or musculoskeletal causes of chest pain, and no formal diagnoses of gastroesophageal reflux disease. Patients were divided into two groups — 314 patients with minimal or no heartburn or regurgitation (≤1 day/week [stratum 1]) and 285 patients with frequent heartburn or regurgitation (≥2 days/week [stratum 2]). Patients were enrolled only if their presenting chest pain was perceived as different from the background heartburn or regurgitation.
Patients were randomized to esomeprazole (Nexium; 40 mg twice daily) or placebo. In stratum 1, the primary efficacy outcome (absence of chest pain during the fourth week of treatment) occurred in 39% of esomeprazole recipients and 26% of placebo recipients — a significant difference (P=0.02). By contrast, in stratum 2, responses were similar in the esomeprazole and placebo groups (27% and 24%; P=0.54).
Flook NW et al. Acid-suppressive therapy with esomeprazole for relief of unexplained chest pain in primary care: A randomized, double-blind, placebo-controlled trial. Am J Gastroenterol 2013 Jan; 108:56. (http://dx.doi.org/10.1038/ajg.2012.369)
Comment
Esomeprazole was effective in some patients with unexplained chest pain and infrequent or no heartburn or regurgitation, but the placebo response was substantial, and eight patients had to be treated to benefit one. A short course of PPI therapy is benign enough that it's worth a try in selected patients with unexplained noncardiac chest pain, but most patients will not benefit.