A 52-year-old man comes to the clinic due to frequent chest pain over the last 6 weeks. The pain typically occurs at night and is described as retrosternal and burning. The patient also has a history of chronic cough and occasional hoarseness. He has coronary artery disease and received a drug-eluting stent after a non-ST elevation myocardial infarction 3 years ago. Current medications include low-dose aspirin, atorvastatin, metoprolol, and losartan. The patient discontinued tobacco use after the myocardial infarction. Vital signs are normal. Examination shows no abnormalities. Resting ECG reveals no significant abnormalities. Exercise ECG reveals 1 mm ST segment depression in the inferior leads at 90% of predicted maximal heart rate, but myocardial perfusion study reveals no evidence of stress-induced ischemia. The patient did not experience chest pain during the stress test. Which of the following is the best treatment for this patient's chest pain?

Question

A 52-year-old man comes to the clinic due to frequent chest pain over the last 6 weeks.  The pain typically occurs at night and is described as retrosternal and burning.  The patient also has a history of chronic cough and occasional hoarseness.  He has coronary artery disease and received a drug-eluting stent after a non-ST elevation myocardial infarction 3 years ago.  Current medications include low-dose aspirin, atorvastatin, metoprolol, and losartan.  The patient discontinued tobacco use after the myocardial infarction.  Vital signs are normal.  Examination shows no abnormalities.  Resting ECG reveals no significant abnormalities.  Exercise ECG reveals 1 mm ST segment depression in the inferior leads at 90% of predicted maximal heart rate, but myocardial perfusion study reveals no evidence of stress-induced ischemia.  The patient did not experience chest pain during the stress test.  Which of the following is the best treatment for this patient's chest pain?

Quizplus · Accepted Answer

11ec25c8_d243_ac95_bc81_d53b00d69dff_MD0003_00 This patient's chest pain is most likely due to gastroesophageal reflux disease (GERD). Chest pain due to GERD can closely resemble anginal chest pain; however, the former is usually prolonged, occurs at rest or after meals, often awakens patients from sleep, and is typically relieved with antacids. In addition, patients with GERD will often have other associated symptoms (eg, cough, hoarseness) caused by reflux of gastric secretions into the larynx or upper pharynx. The initial management of GERD in patients with fewer than 2 episodes of symptoms per week includes lifestyle changes (eg, weight loss, head-of-bed elevation) and histamine 2 receptor antagonists (eg, famotidine, ranitidine) as needed. Patients with more frequent or severe symptoms, evidence of erosive esophagitis, or laryngopharyngeal involvement should be managed with an 8-week course of a proton pump inhibitor (eg, omeprazole, pantoprazole). (Choice A) Alprazolam is a short-acting benzodiazepine that can be used for anxiety or panic attacks; however, due to addictive potential, use of the drug should be minimized or avoided. Panic attacks often present with episodic chest pain, but accompanying dyspnea and a feeling of fear are also expected. (Choice B) Amitriptyline is a tricyclic antidepressant used to treat depression and neuropathic pain. It is not used in the management of GERD. (Choice C) Nonsteroidal anti-inflammatory drugs (eg, ibuprofen) are often used for the management of musculoskeletal chest pain (eg, costochondritis); such pain is usually reproducible with palpation or movement and is not associated with hoarseness or cough. (Choice D) Calcium channel blockers (eg, nifedipine) are used to treat vasospastic (Prinzmetal) angina. Patients have recurrent chest pain that often awakens them from sleep, but associated cough and hoarseness are not typical. (Choice E) Nitroglycerin is typically used to alleviate anginal chest pain. Although this patient's exercise ECG shows ST depression, evidence of ischemia at 90% of maximal heart rate is not unusual in a patient with known coronary artery disease. The normal myocardial perfusion study reassures that his chest pain is not related to myocardial ischemia. Nitroglycerin also commonly relieves GERD chest pain, but it is not an appropriate treatment for GERD. Educational objective: Chest pain due to gastroesophageal reflux disease (GERD) can mimic anginal chest pain. Prolonged episodes of chest pain that occur at rest or after meals, and associated laryngopharyngeal irritation (eg, cough, hoarseness) are suggestive of GERD. Appropriate treatment combines lifestyle changes with a histamine 2 receptor antagonist or proton pump inhibitor (eg, omeprazole). References: Evaluation of chest pain in primary care patients. (http://www.ncbi.nlm.nih.gov/pubmed/21391528)

A 52-Year-Old Man Comes to the Clinic Due to Frequent