非心源性胸痛的评估和处理

Evaluation and Management of Noncardiac Chest Pain

非心源性胸痛(NCCP)是指复发性心绞痛样胸痛,并除外心源性因素,是常见且具有挑战性的临床问题,需经过适当的评估,鉴别症状产生的原因。胃食管反流病(GERD)、食管动力异常和功能性胸痛是NCCP的三大主要病因,其中以GERD最为常见,应首先进行评估。质子泵抑制剂(PPI)试验、上消化道内镜检查、24 h食管pH⁃阻抗监测是评估GERD相关胸痛的常用方法,食管高分辨率测压是鉴别食管动力异常的主要工具,而诊断功能性胸痛需要心脏检查、PPI试验、上消化道内镜检查和活检病理、食管pH⁃阻抗监测和食管测压结果均阴性。NCCP的治疗应根据症状产生的机制选择个体化方案,PPI和平滑肌松弛剂分别是GERD和食管动力异常相关胸痛的常用药物,也可选择内镜和外科手术治疗,神经调节剂(主要为抗抑郁药)则是功能性胸痛的治疗基石。

Noncardiac chest pain(NCCP)is defined as a recurrent,angina⁃like chest pain after cardiac causes are excluded.It is a common and challenging problem in clinical practice that requires appropriate assessment to identify the underlying origin of the symptom.Gastroesophageal reflux disease(GERD),esophageal dysmotility and functional chest pain are the three main causes of NCCP.GERD is the most common cause of NCCP and should be evaluated first.Proton pump inhibitor(PPI)test,upper gastrointestinal endoscopy,24⁃hour esophageal pH⁃impedance monitoring are used to identify GERD⁃induced NCCP.High⁃resolution esophageal manometry is the main tool to identify esophageal dysmotility in non⁃GERD⁃related NCCP.Diagnosis of functional chest pain requires a negative cardiac workup,no response to PPI test,as well as no obvious abnormalities in upper gastrointestinal endoscopy with mucosal biopsy,esophageal pH⁃impedance monitoring and esophageal manometry.Treatment of NCCP is tailored according to the underlying mechanism that is responsible for the chest pain.PPI for GERD⁃related NCCP and smooth muscle relaxants for esophageal dysmotility are very commonly prescribed.Endoscopic and surgical interventions can also be considered in GERD and esophageal dysmotility related NCCP.For patients with functional chest pain,neuromodulators,mainly the antidepressants are the cornerstone of therapy.