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Fifty patients with non-cardiac chest pain underwent 24 hour intraoesophageal pH and pressure recording and provocation tests to determine the relative value of both techniques in establishing the oesophageal origin of the chest pain. Twenty six patients (52%) had at least one positive provocation test: the acid perfusion test was positive related in 18 patients (36%), the edrophonium test in 16 patients (32%), the vasopressin test in five patients (10%), and the balloon distension test (performed in only 20 patients) in one (5%). The 24 hour pH and pressure recording correlated spontaneous chest pain attacks with abnormal motility or gastro-oesophageal reflux in 19 patients (38%). Fourteen of these patients also had at least one positive provocation test. Therefore, 24 hour pH and pressure recordings are only slightly better than a set of provocation tests in identifying the oesophagus as the cause of chest pain (10% diagnostic gain). In the case of oesophageal chest pain, however, 24 hour recording appeared to be the only way to identify the nature of the underlying oesophageal abnormality that caused the spontaneous pain attacks--for example, gastro-oesophageal reflux, motility disorders, or irritability of the oesophagus.

See article on page323 Up to 26% of patients with angina-like chest pain sufficiently severe to necessitate more invasive examinations have normal coronary arteries on arteriography.1 Since the late 1970s, the oesophagus has gained notoriety as a possible cause of the chest pain in these patients. Depending upon the criteria used to accept an oesophageal origin of the pain, up to 50% of patients with normal coronary arteries have oesophageal pain. Gastroenterologists now widely accept that the best and possibly the only way to determine whether the oesophagus is the likely cause of the chest pain is to show a temporal correlation between the pain attack and an abnormal oesophageal event, such as acid reflux or severe motor disturbances. Since the development of 24 hour pH and pressure measurements by the Leuven group, prolonged recordings have become a standard investigation in patients with non-cardiac chest pain.2 These measurements, which attempt to correlate symptoms with abnormal oesophageal events, led to the finding that most of the spontaneous pain attacks were reflux related, although many of these patients have a normal acid exposure on quantitative analysis of 24 hour …