Digestive Diseases and Sciences

, Volume 50, Issue 4, pp 656–661 | Cite as

Attitudes and Referral Patterns of Primary Care Physicians When Evaluating Subjects with Noncardiac Chest Pain—A National Survey

  • Wai-Man Wong
  • Joy Beeler
  • Sara Risner-Adler
  • Sara Habib
  • Jimmy Bautista
  • Ronnie Fass


Noncardiac chest pain (NCCP) may affect up to 23% of the U.S. population. The clinical approach and referral patterns of primary care physicians (PCPs) when evaluating NCCP subjects are unknown. We aimed to determine the preferences of diagnostic tests, referral patterns, and treatment plans of NCCP patients by PCPs. PCPs were randomly selected from the American Medical Association national membership list. A 24-item questionnaire was mailed, which focused on demographic information, characteristics of practice, preferences of diagnostic tests, referral patterns, and treatment plans. Two hundred five (40%) PCPs returned the questionnaire (mean age, 49; 77% males; practice type—community-based, 40.5%; hospital-based, 10.7%; and combined, 47.3%; physician type—internists, 46.3%; family physicians, 44.4%; general practitioners, 4.9%; and others, 2.9%). The mean number of NCCP patients seen in the past 6 months was 108 (6.4% of total patients) and 79.5% were treated primarily by PCPs. The three most common diagnostic tests used were empirical proton pump inhibitor (PPI) trial (45.6%), chest radiograph (39.9%), and upper endoscopy (18.7%). Most PCPs reported that they are either comfortable (44.6%) or very comfortable (21.2%) in diagnosing NCCP. The three most commonly used therapeutic modalities for NCCP were PPIs (37.8%), lifestyle modification (33.7%), and H2 blockers (12.4%). Of those NCCP patients referred to a subspecialist, most ended up in gastroenterology (75.6%), followed by cardiology (7.8%) and pulmonary (1.6%) clinics. We conclude that most PCP’s diagnose and treat NCCP patients without referring them to a gastroenterologist. However, diagnostic and treatment strategies may not follow the current understanding and knowledge of the disorder.


noncardiac chest pain primary care physician gastroesophageal reflux disease survey 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Fass R: Noncardiac chest pain. In GERD/Dyspepsia, 1st ed. Fass R (ed). Philadelphia, PA, Hanley & Belfus, 2004, pp. 183–196Google Scholar
  2. 2.
    Fass R, Malagon I, Schmulson M: Chest pain of esophageal origin. Curr Opin Gastroenterol 17:376–380, 2001PubMedGoogle Scholar
  3. 3.
    Fass R: Chest pain of esophageal origin. Curr Opin Gastroenterol 18:464–470, 2002PubMedGoogle Scholar
  4. 4.
    Locke GR 3rd, Talley NJ, Fett SL, Zinsmeister AR, Melton LJ 3rd: Prevalence and clinical spectrum of gastroesophageal reflux: A population-based study in Olmsted County, Minnesota. Gastroenterology 112:1448–1456, 1997PubMedGoogle Scholar
  5. 5.
    Richter JE, Bradley LA, Castell DO: Esophageal chest pain: Current controversies in pathogenesis, diagnosis, and therapy. Ann Intern Med 110:66–78, 1989PubMedGoogle Scholar
  6. 6.
    Hewson EG, Sinclair JW, Dalton CB, Richter JE: Twenty-four-hour esophageal pH monitoring: The most useful test for evaluating noncardiac chest pain. Am J Med 90:576–583, 1991PubMedGoogle Scholar
  7. 7.
    Janssens J, Vantrappen G, Ghillebert G: 24-hour recording of esophageal pressure and pH in patients with noncardiac chest pain. Gastroenterology 90:1978–1984, 1986PubMedGoogle Scholar
  8. 8.
    DeCaestecker JS, Blackwell JN, Brown J, Heading RC: The oesophagus as a cause of recurrent chest pain: Which patients should be investigated and which tests should be used? Lancet 2:1143–1146, 1985Google Scholar
  9. 9.
    Richter JE, Barish CF, Castell DO: Abnormal sensory perception in patients with esophageal chest pain. Gastroenterology 91:845–852, 1986PubMedGoogle Scholar
  10. 10.
    Mayer EA, Gebhart GF: Basic and clinical aspects of visceral hyperalgesia. Gastroenterology 107:271–293, 1994PubMedGoogle Scholar
  11. 11.
    Mertz HR: Visceral hypersensitivity. Aliment Pharmacol Ther 17:623–633, 2003PubMedGoogle Scholar
  12. 12.
    Fass R, Fennerty MB, Ofman JJ, Gralnek IM, Johnson C, Camargo E, Sampliner RE: The clinical and economic value of a short course of omeprazole in patients with noncardiac chest pain. Gastroenterology 115:42–49, 1998PubMedGoogle Scholar
  13. 13.
    Ofman JJ, Gralnek IM, Udani J, Fennerty MB, Fass R: The cost-effectiveness of the omeprazole test in patients with noncardiac chest pain. Am J Med 107:219–227, 1999PubMedGoogle Scholar
  14. 14.
    Wong WM, Lai KC, Lau CP, Hu WH, Chen WH, Wong BCY, Hui WM, Wong YH, Xia HHX, Lam SK: Upper gastrointestinal evaluation of Chinese patients with non-cardiac chest pain. Aliment Pharmacol Ther 16:465–471, 2002PubMedGoogle Scholar
  15. 15.
    Hsia PC, Maher KA, Lewis JH, Cattau EL Jr, Fleischer DE, Benjamin SB: Utility of upper endoscopy in the evaluation of noncardiac chest pain. Gastrointest Endosc 37:22–26, 1991PubMedGoogle Scholar
  16. 16.
    Frobert O, Funch-Jensen P, Jacobsen NO, Kruse A, Bagger JP: Upper endoscopy in patients with angina and normal coronary angiograms. Endoscopy 27:365–370, 1995CrossRefPubMedGoogle Scholar
  17. 17.
    Stahl WG, Beton RR, Johnson CS, Brown CL, Waring JP: Diagnosis and treatment of patients with gastroesophageal reflux and noncardiac chest pain. South Med J 87:739–742, 1994PubMedGoogle Scholar
  18. 18.
    Cannon RO, Quyymi AA, Mincemoyer R, Stine AM, Gracely RH, Smith WB, Geraci MF, Black BC, Uhde TW, Waclawiw MA, Maher K, Benjamin SB: Imipramine in patients with chest pain despite normal coronary angiograms. N Engl J Med 330:1411–1417, 1994PubMedGoogle Scholar
  19. 19.
    Clouse RE, Lustman PJ, Eckert TC, Ferney DM, Griffith LS: Low-dose trazodone for symptomatic patients with esophageal contraction abnormalities. A double-blind, placebo-controlled trial. Gastroenterology 92:1027–1036, 1987PubMedGoogle Scholar
  20. 20.
    Prakash C, Clouse RE: Long-term outcome from tricyclic antidepressant treatment of functional chest pain. Dig Dis Sci 44:2373–2379, 1999PubMedGoogle Scholar
  21. 21.
    Varia I, Logue E, O’connor C, Newby K, Wagner HR, Davenport C, Rathey K, Krishnan KR. Randomized trial of sertraline in patients with unexplained chest pain of noncardiac origin. Am Heart J 140:367–372, 2000PubMedGoogle Scholar

Copyright information

© Springer Science + Business Media, Inc. 2005

Authors and Affiliations

  • Wai-Man Wong
    • 1
    • 2
  • Joy Beeler
    • 1
  • Sara Risner-Adler
    • 1
  • Sara Habib
    • 1
  • Jimmy Bautista
    • 1
  • Ronnie Fass
    • 1
    • 3
  1. 1.The Neuro-Enteric Clinical Research Group, Section of Gastroenterology, Department of Medicine, Southern Arizona VA Health Care SystemUniversity of Arizona Health Sciences CenterTucsonUSA
  2. 2.Department of Medicine, Queen Mary HospitalUniversity of Hong KongHong Kong
  3. 3.Southern Arizona VA Health Care SystemTucsonUSA

Personalised recommendations