The systematic review and meta-analysis by Wang et al1 focuses on an important issue: assessing the contribution of GERD in noncardiac chest pain (NCCP) by administering short-term, high-dose PPIs. Noncardiac chest pain is a common condition with significant morbidity and economic implications. Unfortunately, the studies included in the meta-analysis were small, and their findings may not be generalizable.
It was not reported by Wang et al1 if the subjective improvement in symptoms of NCCP was followed by an objective evaluation, either additional endoscopic examinations or 24-hour pH monitoring. Another concern is that many patients with NCCP may not have chest pain on a daily basis, because of which ambulatory 24-hour pH monitoring is of limited utility. Because the inclusion criteria for the studies included in the meta-analysis was also based on 24-hour pH monitoring, some patients with infrequent episodes of pain might have been excluded. Considering the cost of 24-hour pH monitoring and its limitations, many experts suggest that 24-hour pH monitoring be reserved for those in whom empirical therapy with a PPI had failed. A number of patients treated with empirical therapy for NCCP will have a placebo response, which may lead to unnecessary and costly long-term therapy. Finally, the study could have been enhanced if evaluation of patients with NCCP included testing to exclude motility abnormalities or the possibility of microvascular angina.2