Since 1768, when Heberden recognized a relationship of
angina pectoris with eating, the close resemblance between angina-like
pain of esophageal and cardiac origin has led to diagnostic
confusion, with the role of the esophagus being, in turn, over- and underemphasized as a cause of symptoms. Although the classic features of angina do not distinguish the origin of the
pain, certain other symptoms may identify esophageal
pain. These include an inconsistent correlation of exercise with
pain, periods of prolonged remission, provocation of
pain by posture, association with other esophageal symptoms, relief by
antacids, radiation of
pain down the right arm and into the back, occurrence of
pain at night, continuation of
pain as a background ache, and relief from nitroglycerine delayed by 10 minutes or longer. However, while certain symptoms may alert the clinician to the possibility that angina-like
pain is due to
esophageal disease, no single symptom or combination of symptoms is infallible; there is no alternative to careful assessment.
Esophageal disease accounts for the greatest number of patients with
chest pain of unknown origin. The prevalence of angina-like esophageal
pain in unselected emergency admissions with suspected
myocardial infarction is 10-20%. Approximately one third or more of patients with angina and normal coronary arteries have esophageal problems. We have followed patients with angina-like esophageal
pain for 9 years. Although prognosis remains good, confirming the original noncardiac diagnosis, greater than 80% of patients continue to have
chest pain of undiminished intensity, and half are limited in their ability to work. Reassurance appeared to have one beneficial result: Patients were less likely to consult a physician after a positive diagnosis had been made.