Acid reflux in patients with coronary artery disease and refractory chest pain

Cardioesophageal Reflex. Should It Trigger Clinician's Response?

Cardiologists and gastroenterologists often encounter the coexistence of symptoms and functional abnormalities, but determining causation is more difficult. In 1962 Smith and Papp first coined the term "linked angina." Their statement was preceded by the experiment whereby increase in bile duct pressure elicited the typical chest pain in patients with ischemic heart disease. It was demonstrated that dysphagia can be associated with ventricular arrhythmia, suggestive of possible cardioesophageal reflex involvement. A potential association between gastroesophageal reflux disease and atrial fibrillation development has been proposed due to the close anatomic vicinity of the esophagus and the left atrium. It has been demonstrated that the patients suffering from prolonged gastro-esophageal acid reflux episodes and coronary spasm may be at higher risk for the development of linked angina and acute myocardial infarction. We believe cardioesophageal reflex is a probable mediator of linked angina. We recommend early treatment of gastroesophageal disorders in patients with symptomatic coronary arterial disease to alleviate the associated ischemic and arrhythmic burden.

Chinese expert consensus on diagnosis and management of gastroesophageal reflux disease in the elderly (2023)

Gastroesophageal reflux disease (GERD) in the elderly is characterized by atypical symptoms, relatively severe esophageal injury, and more complications, and when GERD is treated, it is also necessary to fully consider the general health condition of the elderly patients. This consensus summarized the epidemiology, pathogenesis, clinical manifestations, and diagnosis and treatment characteristics of GERD in the elderly, and provided relevant recommendations, providing guidance for medical personnel to correctly understand and standardize the diagnosis and treatment of GERD in the elderly.

Gastroesophageal reflux disease increases the risk of essential hypertension: results from the Nationwide Readmission Database and Mendelian randomization analysis

BACKGROUND

The link between gastroesophageal reflux disease (GERD) and essential hypertension (EH) and its causal nature remains controversial. Our study examined the connection between GERD and the risk of hypertension and assessed further whether this correlation has a causal relationship.

METHODS

First, we utilized the National Readmission Database including 14 422 183 participants to conduct an observational study. Dividing the population into GERD and non-GERD groups, we investigated the correlation between GERD and EH using multivariate logistic regression. Next, bidirectional two-sample Mendelian randomization was adopted. The summary statistics for GERD were obtained from a published genome-wide association study including 78 707 cases and 288 734 controls. We collected summary statistics for hypertension containing 70 651 cases and 223 663 controls from the FinnGen consortium. We assessed causality primarily by the inverse-variance weighted method with validation by four other Mendelian randomization approaches as well as an array of sensitivity analyses.

RESULTS

In the unadjusted model, GERD patients had a higher risk of EH than the non-GERD group, regardless of gender (odds ratio, 1.43; 95% confidence interval: 1.42-1.43; P < .001). Further adjusting for critical confounders did not change this association. For Mendelian randomization, we found that genetically predicted GERD was causally linked to an enhanced risk of EH in inverse-variance weighted technique (odds ratio, 1.52; 95% confidence interval: 1.39-1.67; P = 3.51 × 10-18); conversely, EH did not raise the risk of GERD causally.

CONCLUSIONS

GERD is a causal risk factor for EH. Further research is required to probe the mechanism underlying this causal connection.

The prevalence of coronary atherosclerosis in patients with refractory gastroesophageal reflux disease ready for antireflux surgery

Coronary atherosclerosis (CAS) and gastroesophageal reflux disease (GERD) share common risk factors. The existing CAS may not only increase the possibility of GERD to be refractory GERD (RGERD), but also increase the risk of antireflux surgery for these patients. The aim of this study was to estimate the prevalence of CAS and its potential risk factors in patients with RGERD ready for antireflux surgery. The retrospective analysis was performed in the digestive disease center of Suining Central Hospital, a teritary hospital in Sichuan, China. Records of patients with RGERD admitted to the hospital for antireflux surgery between July 2018, and June 2021 were included. The included patients were divided into the RGERD group and RGERD-CAS group based on the coronary computed tomography angiography (CCTA) results, which were defined as no CAS and CAS (<50% mild stenosis or ≥50% significant stenosis). In total, 448 patients with RGERD qualified for the study. The prevalence of CAS in these patients was 45.1%. Specifically, 246 patients (54.9%) were in the RGERD group, and 202 patients (45.1%) were in the RGERD-CAS group. Among these 202 patients with CAS, 120 patients (59.4%) had mild CAS (<50% stenosis), 82 patients (40.6%) had significant CAS (≥50% stenosis). Five independent risk factors, including male sex, high blood pressure (HBP), diabetes mellitus (DM), Barrett's esophagus (BE) and family history of coronary artery disease were identified for the occurrence of CAS in patients with RGERD ready for antireflux surgery after adjusting for other factors. CAS is prevalent in patients with RGERD ready for antireflux surgery. Routing CTTA was suggested to exclude potential coronary artery disease in RGERD patients ready for antireflux surgery with independent risk factors.

Risk of acute myocardial infarction in patients with gastroesophageal reflux disease: A nationwide population-based study

Objective

Gastroesophageal reflux disease (GERD) is a common disease which can cause troublesome symptoms and affect quality of life. In addition to esophageal complications, GERD may also be a risk factor for extra-esophageal complications. Both GERD and coronary artery disease (CAD) can cause chest pain and frequently co-exist. However, the association between GERD and acute myocardial infarction (AMI) remain unclear. The purpose of the study was to compare the incidence of acute myocardial infarction in GERD patients with an age-, gender-, and comorbidity matched population free of GERD. We also examine the association of the risk of AMI and the use of acid suppressing agents in GERD patients.

Methods

We identified patients with GERD from the Taiwan National Health Insurance Research Database. The study cohort comprised 54,422 newly diagnosed GERD patients; 269,572 randomly selected age-, gender-, comorbidity-matched subjects comprised the comparison cohort. Patients with any prior CAD, AMI or peripheral arterial disease were excluded. Incidence of new AMI was studied in both groups.

Results

A total 1,236 (0.5%) of the patients from the control group and 371 (0.7%) patients from the GERD group experienced AMI during a mean follow-up period of 3.3 years. Based on Cox proportional-hazard model analysis, GERD was independently associated with increased risk of developing AMI (hazard ratio (HR) = 1.48; 95% confidence interval (CI): 1.31–1.66, P < 0.001). Within the GERD group, patients who were prescribed proton pump inhibitors (PPIs) for more than one year had slightly decreased the risk of developing AMI, compared with those without taking PPIs (HR = 0.57; 95% CI: 0.31–1.04, P = 0.066).

Conclusions

This large population-based study demonstrates an association between GERD and future development of AMI, however, PPIs use only achieved marginal significance in reducing the occurrence of AMI in GERD patients. Further prospective studies are needed to evaluate whether anti-reflux medication may reduce the occurrence of acute ischemic event in GERD patients.

Health-related quality of life in gastroesophageal reflux patients with noncardiac chest pain: Emphasis on the role of psychological distress

AIM

To investigate the effects of depression and anxiety on health-related quality of life (QoL) in gastroesophageal reflux disease (GERD) patients and those suffering from cardiac (CCP) and noncardiac (NCCP) chest pain in Wuhan, China.

METHODS

In this cross-sectional study, a total of 358 consecutive patients with GERD were enrolled in Wuhan, China, of which 176 subjects had complaints of chest pain. Those with chest pain underwent coronary angiography and were divided into a CCP group (52 cases) and NCCP group (124 cases). Validated GERD questionnaires were completed, and the 36-item Short-Form Health Survey and Hospital Anxiety/Depression Scale were used for evaluation of QoL and psychological symptoms, respectively.

RESULTS

There were similar ratios and levels of depression and anxiety in GERD with NCCP and CCP. However, the QoL was obviously lower in GERD with CCP than NCCP (48.34 ± 17.68 vs 60.21 ± 20.27, P < 0.01). In the GERD-NCCP group, rather than the GERD-CCP group, the physical and mental QoL were much poorer in subjects with depression and/or anxiety than those without anxiety or depression. Anxiety and depression had strong negative correlations with both physical and mental health in GERD-NCCP (all P < 0.01), but only a weak relationship with mental components of QoL in GERD-CCP.

CONCLUSION

High levels of anxiety and depression may be more related to the poorer QoL in GERD patients with NCCP than those with CCP. This highlights the importance of evaluation and management of psychological impact for improving QoL in GERD-NCCP patients.

Association between gastroesophageal reflux disease and coronary heart disease: A nationwide population-based analysis

In this study, we aimed to determine the association between gastroesophageal reflux disease (GERD) and subsequent coronary heart disease (CHD) development, if any, and to evaluate whether longer use of proton pump inhibitors (PPIs) increases the risk of CHD.Patients diagnosed with GERD between 2000 and 2011 were identified as the study cohort (n = 12,960). Patients without GERD were randomly selected from the general population, frequency-matched with the study group according to age, sex, and index year, and evaluated as the comparison cohort (n = 51,840). Both cohorts were followed up until the end of 2011 to determine the incidence of CHD. The risk of CHD was evaluated in both groups by using Cox proportional hazards regression models.The GERD patients had a greater probability of CHD than the cohort without GERD did (log-rank test, P < 0.001 and 11.8 vs 6.5 per 1000 person-years). The GERD cohort had a higher risk of CHD than the comparison cohort did after adjustment for age, sex, hypertension, diabetes, hyperlipidemia, alcohol-related illness, stroke, chronic obstructive pulmonary disease, asthma, biliary stone, anxiety, depression, chronic kidney disease, and cirrhosis (adjusted hazard ratio [aHR]: 1.49, 95% confidence interval [CI]: 1.34-1.66). The risk of CHD was greater for the patients treated with PPIs for more than 1 year (aHR = 1.67, 95% CI = 1.34-2.08) than for those treated with PPIs for <1 year (aHR = 1.56, 95% CI = 1.39-1.74).Our population-based cohort study results indicate that GERD was associated with an increased risk of developing CHD, and that PPI use for more than 1 year might increase the risk of CHD.

The association between cardiac and gastrointestinal disorders: causal or casual link?

Cardiovascular diseases are the leading cause of death worldwide: among them, coronary artery disease and arrhythmias represent the most frequent pathological conditions. Similarly, the gastrointestinal disorders, that is, gastroesophageal reflux and inflammatory bowel diseases, have a high incidence in the general population. Several pieces of evidence have documented a link between cardiac and gastrointestinal disorders as they often share similar risk factors and symptoms. Furthermore, both can simultaneously occur in the same patient, thus creating problems in the correct clinical diagnosis. It is well known that gastrointestinal disorders may present with chest pain and mimic angina pectoris. In contrast, they can also unmask heart disease, such as in the case of the angina-linked ischemia. The aim of this review was to elucidate the mechanisms underlying the relationship between cardiac and gastrointestinal diseases to better understand the causal or casual character of such a linkage.

Value of the Gastroesophageal Reflux Disease Questionnaire (GerdQ) in predicting the proton pump inhibitor response in coronary artery disease patients with gastroesophageal reflux-related chest pain

Chest pain experienced by patients with coronary artery disease can be partly due to gastroesophageal reflux-induced chest pain (GERP). Empirical proton pump inhibitor (PPI) therapy has been recommended as an initial clinical approach for treating GERP. However, PPI use may lead to some health problems. The Gastroesophageal Reflux Disease Questionnaire (GerdQ) may represent a noninvasive and cost-effective approach for avoiding PPI misuse and for identifying the appropriate patients for the PPI trial test. The aim of this pilot study was to prospectively evaluate the association between GerdQ scores and PPI response in patients with coronary artery disease (CAD) and GERP to determine whether the GerdQ predicts the PPI response in patients with CAD and GERP and to further validate the clinical application value of the GerdQ. A total of 154 consecutive patients with potential GERP were recruited to complete a GerdQ with subsequent PPI therapy. Based on the PPI trial result, patients were divided into a PPI-positive response group and a PPI-negative response group. The difference in the GerdQ scores between the two groups was assessed. The receiver operating characteristic (ROC) curve of GerdQ score was drawn according to the PPI response as the gold standard. The ability of GerdQ to predict the PPI response was assessed. A total of 96 patients completed the entire study; 62 patients (64.6%) were assigned to the PPI-positive response group, and 34 patients (35.4%) to the PPI-negative response group. The GerdQ score of the PPI-positive response group (8.11 ± 3.315) was significantly higher than that of the PPI-negative response group (4.41 ± 2.743), and the difference was statistically significant (t = 5.863, P = 0.000). The ROC curve was drawn according to a PPI response assessment result with a score above 2 as the gold standard. The area under curve was 0.806. When the critical value of GerdQ score was 7.5, Youden index was up to 0.514, the diagnostic sensitivity was 0.661, and the diagnostic specificity was 0.853. A GerdQ score greater than 7.5 better predicts the response to the PPI trial therapy. There is a strong association between the GerdQ score and the response to PPI therapy. Higher GerdQ scores were predictive of a positive PPI response in CAD patients with GERP. The GerdQ may be a reasonable screening tool for GERP in patients with CAD who are prepared to accept PPI therapy.

Acute Coronary Syndrome: An Unusual Consequence of GERD

We report a case of an 83-year-old man with history of coronary artery disease and gastroesophageal reflux disease (GERD) who presented with sudden onset nocturnal dyspnea. He was diagnosed with non-ST elevation myocardial infarction based on the electrocardiographic changes and cardiac biomarker elevation. Cardiac catheterization revealed chronic three-vessel coronary artery disease, with 2 patent grafts and 2 chronically occluded grafts. While at the hospital, the patient experienced a similar episode of nocturnal dyspnea, prompting a barium esophagram, which was suggestive of a stricture in the distal esophagus from long-standing GERD. We hypothesized that he had myocardial ischemia due to increased oxygen demand from uncontrolled GERD symptoms. He had no further ischemic episodes after increasing the dose of antireflux medication over a 6-month follow-up. After presenting our case, we review the literature on this atypical presentation of GERD causing acute coronary syndrome and discuss potential mechanisms.