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Effort-related chest pain and chest pain fulfilling the criteria of the Rose questionnaire for angina pectoris are often used as evidence for coronary heart disease. In patients with different kinds of oesophageal dysfunction (OD) the frequency of chest pain of angina-like type was studied and compared to that in the general population. Eighty per cent of patients with hiatal hernia at oesophageal manometry had chest pain, 63% of which was effort-related. In 217 patients with a positive acid perfusion test, i.e. the provoked heart burn or pain is the same as that experienced in daily life, 82% had a history of chest pain. The chest pain was effort-related in 70% and in almost half of the cases their chest pain was classified as angina pectoris according to the Rose questionnaire. Since angina-like chest pain is a predominant symptoms in patients with OD and OD is far more common than angina pectoris due to myocardial ischemia in the general population, it is reasonable to assume that the oesophagus and not the heart is the most common source of angina-like chest pain.

Questionnaires aimed at detecting angina pectoris and oesophageal dysfunction (OD) were used in 281 patients with central chest pain of a type which gave suspicion of ischaemic heart disease (IHD). Signs of IHD were found in 208 patients (74%), 172 of whom had a positive angina pectoris questionnaire. The sensitivity of the questionnaire regarding the diagnosis of IHD was 83%, the specificity 48% and the predictive accuracy 82%. OD was found in 137 of the of the 281 patients (49%). "Do you often have heartburn" was the question which distinguished the OD and non-OD groups the best (p less than 0.001). The sensitivity of this question in detecting OD was 34%, the specificity 93% and the predictive accuracy 82%. In conclusion, the diagnostic value of the angina pectoris questionnaire was limited by a low specificity and the diagnostic value of the oesophageal questionnaire by a low sensitivity in these patients with chest pain.

Oesophageal function and symptoms were investigated in 52 male patients 2-6 months after an acute myocardial infarction. Oesophageal function was tested by manometry, pH recording and acid perfusion test. Signs of oesophageal dysfunction (OD) were found in 17 patients (33%). This frequency did not differ significantly from that in a random male population sample, but was lower than in a group of male coronary care unit patients with no signs of a new or earlier myocardial infarction at discharge from hospital (p less than 0.05). All but two patients affirmed chest pain by questionnaire. At a verbal interview, 38 patients (73%) had a history of angina pectoris after discharge from hospital. Thirty-five (92%) of these patients had an ischaemic ECG reaction and/or recurrence of their anginal chest pain during the exercise test, one of them also had evidence of oesophageal origin of his chest pain. There were no signs of OD in the remaining three patients with a history of angina pectoris. Therefore, OD does not constitute a common problem in the differential diagnosis of anginal chest pain in patients with recent myocardial infarction.

Twenty-eight male patients referred to work ECG due to chest pain, all with a positive oesophageal symptom questionnaire believed to detect oesophageal dysfunction (OD), have been subjected to a graded work test and an oesophageal manometry test and answered a questionnaire believed to detect effort angina. Ischaemic heart disease (IHD) was defined as earlier infarction on ECG at rest or a pathological effort ECG. OD was defined as a positive acid perfusion test, hernia or a clear dysmotility in combination with a lower sphincter incompetence. Twenty patients had a positive effort angina questionnaire. Among these, OD was more common (n = 13) than IHD (n = 8). Five of the 20 patients had signs of both IHD and OD. Eight patients had a negative effort angina questionnaire; OD was found in 7 and IHD in 1 of these patients. It is concluded that in cases with angina-like chest pain OD should be considered.

Oesophageal motility was studied in 59 patients before and again after prolonged acid perfusion. In group 1 (n = 16), who were asymptomatic during the acid perfusion, no significant motility differences were obtained by perfusion. In group 2 (n = 18), who had heartburn, and in group 3 (n = 25), who had angina-like chest pain during acid perfusion, significant (p less than 0.01-0.001) changes of motility were seen: these included higher peristaltic amplitude, longer contraction duration, and slower peristaltic velocity. In addition, patients in group 3 showed a decrease (p less than 0.01) of peristaltic propagation and had secondary wave activity more often (p less than 0.01) during acid perfusion. Significantly (p less than 0.01) more patients in group 3 showed secondary wave activity after acid perfusion than in group 2. Pretest motility investigation did not separate the two acid-sensitive groups from the acid-unsensitive one, whereas the investigation of the lower oesophageal sphincter (LOS) did. Thus, LOS incompetence was significantly (p less than 0.01) commoner in the two symptomatic groups than in the asymptomatic group. We suggest that the motility changes observed during acid perfusion are secondary to increased sensory stimulation from the oesophagus but are not the cause of the symptoms. However, nervous reflex reactions from other chest organs, such as the heart, may also explain the results.

Out of 121 patients referred to a work test on account of chest pain, 67 with a case history typical for oesophageal dysfunction have been further investigated with an acid perfusion test during continuous ECG monitoring. Neither arrhythmias nor ST-T changes were induced by the procedure. Of the 67 patients, 6 had a "positive related" acid perfusion test, 23 a "positive unrelated" and the remainder a negative test. Five of the 14 patients with pathological effort ECG belonged to the group with a positive acid perfusion test. The acid perfusion test, as a safe routine in close connection with the effort ECG in selected patients, is a useful technique for establishing whether or not the patient's symptoms have an oesophageal component.

Among 55 consecutive coronary care unit (CCU) patients with chest pain of unknown origin at discharge from hospital, signs of oesophageal dysfunction (OD) were found in 58% and signs of ischaemic heart disease (IHD) in 35% within 2-6 months. At a three-year follow-up, signs of OD were found in 62% and signs of IHD in 28%. Forty-six patients (84%) had experienced a pain similar to that which caused the CCU admission (i.e. the CCU chest pain). OD was regarded as the cause of the CCU chest pain in seven patients (13%) and as a possible cause in another nine (16%). IHD was regarded as the cause of the CCU chest pain in 17 patients (31%), four of whom had died from acute myocardial infarction during the follow-up period. All ten patients who developed coronary events, such as myocardial infarction or progressive angina pectoris, during the follow-up period had an ischaemic ECG reaction at exercise test 2-6 months after discharge from the CCU. IHD was found to be the predominant disease in terms of severity of symptoms and prognosis and was also recorded as the most common single cause of the CCU chest pain. Since OD was common and even caused severe chest pain in some patients, oesophageal origin should be considered in the differential diagnosis of chest pain in non-infarction CCU patients.

A short review of the literature of the acid perfusion test is first given. Data from 67 patients with chest pain investigates with an acid perfusion test during ECG-surveillance in close connection to an exercise test are then presented. Arrhythmias or ST-T changes on ECG were not induced by the acid infusion. Six patients had a "positive related" acid perfusion test which in this context means that they recognized the chest discomfort elicited by the acid infusion as that which had brought them to the exercise test. The acid perfusion test in close connection to an exercise test is in selected patients a safe and useful technique for establishing whether or not the symptoms have an oesophageal component.

Sixty-four patients with a history of disabling chest pain belonging to groups III or IV classified according to the NYHA criteria were examined with oesophageal function tests, coronary angiography and bicycle ergometry and also answered a symptom questionnaire. At the exercise test, 52 had effort angina; 45 (89%) of them had a pthological coronary angiogram and 22 (42%) had signs of oesophageal dysfunction (OD). OD as the single possible etiological factor for typical effort angina therefore seemed unlikely. Chest pain was absent or atypical at the exercise test in 12 patients, 11 (92%) of whom had signs of OD. This incidence is significantly higher (p less than 0.01) than that found in the patients with effort-related chest pain. Five (42%) of the 12 patients with atypical chest pain at the exercise test had a pathological coronary angiogram, an incidence which is significantly lower (p less than 0.001) than that found in the group with effort-related chest pain. In patients with a history of disabling chest pain but with atypical chest pain in connection with the exercise test, OD was more frequent than coronary disease and therefore more likely to have caused the symptoms.