Проблеми та можливості діагностики рефлюкс-індукованої кардіалгії в осіб похилого віку на первинному рівні медичної допомоги

There are data suggesting that 20–40% of the global population exhibits symptoms representative of gastroesophageal reflux disease (GERD). GERD is more commonly diagnosed in mature, elderly, and senile individuals, accounting for approximately 23% among this group. The presence of comorbidities, the rate of which is increased with age, in combination with atypical extraesophageal GERD manifestations, particularly, cardialgia, form additional challenges for timely diagnosis of coronary heart disease (CHD) and management of patients, especially at the primary care level. The objective: to study the causes and manifestations of cardialgia in elderly patients which are associated with GERD and to provide general practitioners with recommendations regarding medical management for this category of patients. Materials and methods. A study was conducted on 69 patients, in whom the indicators of gastric acid-forming function, indicators of basal gastric secretion, the presence of comorbid pathology and reflux score were studied. The features of electrocardiogram (ECG) changes depending on the number of refluxes were determined. Results. In 20 patients (37%), no significant number (above normal) of gastroesophageal reflux (GER) episodes were detected. However, episodes of ST-segment depression on ECG were more than 2 mm in depth and lasted from 5 to 83 minutes. This allowed us to associate the pain in these patients with the presence of CHD. In 19 patients (33%), a significant number of GER episodes (> 50) was recorded, while no changes were observed on Holter ECG monitoring, which allowed us to associate this pain with extraesophageal non-cardiac manifestations of GERD. In 6 (11%) patients, both a significant number of reflux episodes (> 50) and ischemic changes on ECG were found. During the study, episodes of ST-segment depression occurred 2 to 9 times per day in these patients. In 2 of these patients, the clinical picture was similar, but the reflux episodes and ECG changes were not temporally correlated. In 3 other patients, an increased rate of GER was observed 10–15 minutes prior to ECG changes, in one of these cases, supraventricular extrasystoles occurred during the GER spike. In 10 (19%) patients, despite having complaints, no abnormalities were detected during simultaneous monitoring. Thus, the method of simultaneous 24-hour pH and ECG monitoring used in this study expands the possibilities for understanding the causes, conditions, and nature of cardialgia. In some patients, it allows for differential diagnosis between GERD and CHD, as well as the recognition of their combined presence. There is a reason to believe that in some cases, GER in GERD acts as a trigger mechanism for manifestations in the form of pain similar to cardialgia, which can be assessed as angina attacks. Given the diagnostic difficulties of differential diagnosis of cardialgia in the elderly, an algorithm of actions for a doctor at the primary level of medical care has been developed. Conclusions. GERD, defined as a chronic, recurrent condition which is characterized by spontaneous or regularly repeated reflux of gastric and duodenal contents into the esophagus, combined with cardialgia, poses specific challenges for primary care physicians in terms of differential diagnosis. In some elderly patients, the coexistence of GERD and CHD is highly probable, even in the absence of pronounced pain, and this must be taken into account when prescribing antianginal medications that contribute to the relaxation of the lower esophageal sphincter. Timely diagnosis and treatment, as well as adherence to lifestyle recommendations, improve the prognosis of GERD and reduce its impact on the development of cardialgia. In addition to treating GERD with proton pump inhibitors and H2-receptor antagonists, depending on the severity (classified as A, B, C or D), patients should be advised to follow simple lifestyle measures, such as: elevating the head of the bed (in cases of nighttime symptoms); reducing body mass index (obesity plays a key role in the development of refractory GERD). In the presence of GERD there is a risk of developing Barrett’s esophagus, adenocarcinoma, strictures and dysphagia, which should be taken into account by the general practitioner – family medicine during long-term monitoring of the patient.