MKSAP: 60-year-old woman with substernal chest pain

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 60-year-old woman is evaluated for a 3-week history of substernal chest pain. The pain is dull, nonradiating, and unrelated to activities. Sometimes the pain is worse after eating spicy foods and can be occasionally triggered by emotional stress. She has not had shortness of breath or weakness. She is moderately active, walking a mile each day. She generally eats a “healthy heart” diet but has never had her lipid levels evaluated. She has never smoked cigarettes. There is no family history of heart disease. Other than the current problem, she is well and takes no medications.

On physical examination, blood pressure is 135/75 mm Hg, pulse rate is 70/min, and respiration rate is 12/min. The remainder of the examination is normal.

An electrocardiogram is normal.

Which of the following is the appropriate next step in management?

A. Ambulatory pH testing
B. Esophageal manometry
C. Exercise stress test
D. Upper endoscopy

MKSAP Answer and Critique

The correct answer is C. Exercise stress test.

The most appropriate next step in management is an exercise stress test. Chest pain caused by esophageal disorders can be difficult to distinguish from cardiac chest pain because of the anatomic proximity and common innervation of the esophagus and the heart. Esophageal chest pain is often prolonged, nonexertional, and associated with other esophageal symptoms such as dysphagia, odynophagia, or reflux. The most common cause of noncardiac chest pain is untreated gastroesophageal reflux disease (GERD), followed by motility disorders. Owing to the potentially life-threatening consequences of untreated cardiac chest pain, a cardiac evaluation must be performed and cardiac causes must be ruled out before attributing chest pain to an esophageal cause. In addition, the rationale for evaluating this patient for coronary artery disease is particularly compelling. She has atypical chest pain. Atypical chest pain meets two of the three diagnostic criteria for typical chest pain: substernal in location, provoked by exertion or emotional distress, relieved by rest or nitroglycerin. Taking into account the description of the chest pain, sex, and age, this patient has a 51% pretest probability of coronary artery disease and should be further evaluated with an exercise stress test. If this patient’s cardiac evaluation is negative, she should receive an empiric trial of a proton pump inhibitor. If symptoms resolve, this confirms the diagnosis of GERD.

Ambulatory pH testing is used to identify patients with GERD. Esophageal manometry testing will identify an underlying motility disorder of the esophagus. Lastly, upper endoscopy is used to identify mucosal inflammation in the upper gastrointestinal tract. These tests should be performed only after a cardiac condition has been ruled out as the cause of this patient’s chest pain.

Key Point

  • Although gastroesophageal reflux disease (GERD) is the most common cause of noncardiac chest pain, a cardiac evaluation should be considered to rule out cardiac causes before initiating treatment for GERD.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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