What is the next best step in managing a 75-year-old man with intermittent chest pain at rest or with exertion, a distant history of Myocardial Infarction (MI), no Electrocardiogram (EKG) changes, and a normal stress test, who experiences relief from chest pain with water intake?

From the Guidelines

The next best step in managing this 75-year-old man with chest pain relieved by water intake is to evaluate for esophageal disorders, particularly gastroesophageal reflux disease (GERD). Given his normal stress test and lack of EKG changes despite symptoms, along with the characteristic relief from water intake, the pain is likely non-cardiac in origin. The patient should undergo an empiric trial of a proton pump inhibitor such as omeprazole 20mg once daily before breakfast for 4-8 weeks, as suggested by the most recent and highest quality study available 1. If symptoms improve, this supports a GERD diagnosis. Additionally, lifestyle modifications should be implemented, including:

• Avoiding meals within 3 hours of bedtime
• Elevating the head of the bed
• Avoiding trigger foods like caffeine, chocolate, and fatty meals If symptoms persist despite PPI therapy, referral to a gastroenterologist for further evaluation with endoscopy would be appropriate to rule out other esophageal disorders such as esophageal spasm or achalasia. The relief with water intake is a classic feature of esophageal pain, as it helps wash acid back into the stomach or relieve esophageal spasm. While the patient has a history of MI, the current presentation and normal cardiac workup suggest a non-cardiac etiology that warrants investigation of the gastrointestinal system, in line with the recommendations for initial cardiac testing to establish diagnosis of IHD 1. The European Society of Cardiology guidelines also support a comprehensive approach to diagnosing and managing stable angina, but in this case, the patient's symptoms and normal cardiac tests point towards a non-cardiac cause 1.

From the FDA Drug Label

Nitroglycerin sublingual tablets can relieve this pain. One tablet should be dissolved under the tongue or in the oral cavity at the first sign of chest pain. The dose may be repeated approximately every 5 minutes, until the chest pain is relieved The next best step in managing a 75-year-old man with intermittent chest pain at rest or with exertion, a distant history of Myocardial Infarction (MI), no Electrocardiogram (EKG) changes, and a normal stress test, who experiences relief from chest pain with water intake, is to consider nitroglycerin sublingual tablets for relief of angina symptoms.

• The patient should be instructed to take one tablet at the first sign of chest pain, which can be repeated every 5 minutes until relief is obtained.
• It is essential to note that if the pain persists after a total of 3 tablets in a 15-minute period, or if the pain is different than typically experienced, prompt medical attention is recommended 2.
• Additionally, the patient should be advised to sit down when taking nitroglycerin sublingual tablets and use caution when standing up to avoid lightheadedness or dizziness 2.

From the Research

Patient Profile

• 75-year-old man with intermittent chest pain at rest or with exertion
• Distant history of Myocardial Infarction (MI)
• No Electrocardiogram (EKG) changes
• Normal stress test
• Experiences relief from chest pain with water intake

Potential Causes and Next Steps

• The patient's symptoms and history suggest a possible cardiac or non-cardiac cause for the chest pain
• Given the patient's age and history of MI, cardiac causes such as coronary artery disease or cardiac ischemia should be considered 3, 4, 5
• However, the normal stress test and lack of EKG changes make cardiac causes less likely
• Non-cardiac causes such as gastroesophageal reflux disease (GERD) or esophageal spasm should also be considered 6, 7
• The fact that drinking a glass of water sometimes provides relief from chest pain suggests a possible esophageal cause

Diagnostic and Therapeutic Options

• Further diagnostic testing such as endoscopy or ambulatory pH monitoring may be necessary to rule out non-cardiac causes of chest pain
• If GERD is suspected, a trial of acid suppression therapy with a proton pump inhibitor such as omeprazole may be beneficial 6
• If esophageal spasm is suspected, a trial of oral nitroglycerin solution may be considered 7
• Aspirin therapy may be considered for primary prevention of cardiovascular disease, but the decision to initiate aspirin use should be individualized based on the patient's risk factors and bleeding risk 3, 4, 5