Case Western Reserve University School of Medicine Cleveland, OH
Ehsan Chitsaz, MD, MHSc1, Sara Ghoneim, MD2, Fahmi Shibli, MD3, Ronnie Fass, MD, FACG3; 1Case Western Reserve University School of Medicine, Cleveland, OH; 2MetroHealth Medical Center, Cleveland, OH; 3MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
Introduction: Non cardiac chest pain (NCCP) is among the most common conditions evaluated in the primary and specialty outpatient clinics. Gastroesophageal Reflux Disease (GERD) is the most common cause of NCCP. A treatment trial with proton pump inhibitor test, also known as the “PPI-test" is commonly for the diagnosis of GERD-related NCCP. However, the studies evaluating the accuracy of this diagnostic modality have shown variable results in the past due to variable definition of the PPI test as well as inconsistent inclusion of the studies. We aim to perform a meta-analysis that evaluates the accuracy of the well-defined PPI-test in diagnosing NCCP using only controlled clinical trials. Methods: We performed a systematic review of the controlled clinical trials examining a short course (1, 2 or 4 weeks) of high dose PPI as a diagnostic test for patients with suspected GERD that were published between Jan 01, 1950 and Feb 01, 2020. MEDLine, Web of Science, and Cochrane Controlled Register of Trials (CENTRAL) were systematically searched with controlled vocabulary as well as key word searching. Hand searching and cross reference checking was performed. A total of 3874 studies were screened and 14 studies were included in the final analysis. We calculated the pooled sensitivity, specificity, positive and negative likelihood ratios (LR), pooled Diagnostic Odds Ratio (DOR), and pooled positive predictive value (PPV) and negative predictive values (NPV)and SROC curves were examined. We used random effects model in Meta-DiSc Version 1.4 to calculate pooled estimates and the corresponding 95% confidence intervals. Results: A total of 8 studies that included. 285 patients met the inclusion criteria. The pooled estimates for both sensitivity and specificity of PPI test were 78% (70%-84%) and corresponding positive and negative likelihood ratios were estimated at 3.21 (2.36 - 4.36) and 0.30 (0.20-0.43) respectively and diagnostic odds ratio (DOR) was 17.2 (8.84-33.7). After sensitivity analysis, and removal of a study with suboptimal randomization, the heterogeneity index I 2 markedly decreased from 39% to 0% and the respective pooled estimates indicated sensitivity of 82%, specificity of 78%, positive likelihood ratio of 3.31, negative likelihood ratio of 0.25, and diagnostic odds ratio of 21.24. Discussion: PPI-test, defined as clinical response to diagnostic trial with high dose PPI for 1-4 weeks confers high diagnostic accuracy for GERD-related non-cardiac chest pain.
Fig-1: Pooled sensitivity and specificity of PPI test in diagnosing GERD-related non-cardiac chest pain
Fig-2: Pooled Diagnostic Odds ratio (DOR) and summary receiver operating characteristics (SROC) of PPI test in diagnosing GERD-related non-cardiac chest pain
Disclosures: Ehsan Chitsaz indicated no relevant financial relationships. Sara Ghoneim indicated no relevant financial relationships. Fahmi Shibli indicated no relevant financial relationships. Ronnie Fass indicated no relevant financial relationships.