MKSAP quiz: Management of atypical chest pain

This month's quiz asks readers to determine the most appropriate course of management for a 56-year-old woman with chest discomfort that intermittently occurs after meals and while walking up stairs.


A 56-year-old woman is evaluated for chest discomfort after meals occurring intermittently over the preceding month. She describes a sensation of heaviness on her chest, and says that she also notices this pain sometimes while walking up stairs. She reports no nausea, dysphagia, or reflux. She has been taking ranitidine with minimal relief of symptoms. She also takes atorvastatin for hyperlipidemia. She smokes half a pack of cigarettes daily.

On physical examination, her blood pressure is 140/90 mm Hg and other vital signs are normal; BMI is 34. The remainder of the examination, including abdominal examination, is unremarkable.

Which of the following is the most appropriate next step in management?

A. Barium esophagography
B. Electrocardiography
C. Empiric trial of a proton pump inhibitor
D. Upper endoscopy


MKSAP Answer and Critique

The correct answer is B. Electrocardiography. This content is available to MKSAP 18 subscribers as Question 57 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.

The most appropriate next step in management of this patient is electrocardiography followed by evaluation for cardiac disease. Although gastroesophageal reflux disease (GERD) can present with symptoms of chest pain, this patient's pain is also exertional (occurs while walking up stairs), which is not typical in GERD. Failure to identify underlying cardiac disease in the setting of atypical chest pain can be catastrophic. Although this patient may have GERD, it is essential to evaluate her for heart disease before beginning empiric treatment for GERD. GERD is the most common cause of noncardiac chest pain, and chest pain caused by esophageal disorders can be difficult to distinguish from cardiac chest pain because of the anatomic proximity and common innervation of the esophagus and the heart.

Barium esophagography is recommended as the initial test for evaluation of dysphagia but is not recommended for the evaluation of typical GERD symptoms.

In patients with typical GERD symptoms, no additional testing is required and an empiric trial of a proton pump inhibitor (PPI) can be initiated. Failure to improve after 8 weeks of standard therapy should prompt further evaluation. In patients with atypical chest pain, treatment with a PPI is appropriate after ruling out cardiac disease as a cause of the chest pain.

An upper endoscopy is indicated in patients with gastrointestinal alarm symptoms such as anemia, dysphagia, or unintentional weight loss. Upper endoscopy is the primary tool to evaluate mucosal inflammation in the upper gastrointestinal tract.

Key Point

  • In patients with atypical chest pain, a cardiac cause must be ruled out before starting treatment for gastroesophageal reflux disease.