Oesophageal chest pain.

Correspondence Oesophageal chest pain SIR,-We would like to make three comments on the leading article by Drs Blackwell and Castell in the January issue of Gut. 1 They point the need for studies of oesophageal motility during effort angina in patients with proven coronary artery disease: we would refer them to our publications reporting that in six such patients we found no associated evidence of significant oesophageal dysmotility from simultaneous mano-metric studies. 3 They note the lack of controlled trials in the treatment of this condition: we would refer them to our preliminary report of a double blind, placebo controlled trial of nifedipine4 (a further paper in preparation). They comment on the dangers of ergometrine and the advantages of edrophonium. We find the ergo-metrine test useful3 5 6 and believe that it is safe, provided that patients are first carefully screened from the cardiological point of view and are shown not to have coronary artery disease, and that the oesophageal study is conducted with electrocardio-graphic monitoring and resuscitative facilities to hand, giving ergometrine in an initial dose of 0 05 mg, doubling every two to three minutes to a total of 0 5 mg over ca 10 minutes. We would point out that edrophonium is a cholinesterase inhibitor7 and that methacholine (a cholinergic agent and thus a vaso-constrictor) is capable of inducing coronary spasm in susceptible subjects8 9 so that the authors' suggestion that edrophonium is safer than ergo-metrine seems likely to represent a type II error. Because edrophonium has not yet been shown to induce coronary spasm does not mean that it does not. We would caution against accepting the view that edrophonium is safe on present evidence.Angina" and normal coronary arteriograms: a follow up study.s variant angina. Coronary arteriogram and left ventriculogram during angina attack induced by methacholine. Role of autonomic nervous system in the pathogenesis of prinzmetal variant form of angina. Reply SIR,-We were very interested to receive the observations from Dr Alban Davies and his colleagues on our leading article and we are pleased to have the opportunity to respond to them. In order to interpret the high prevalence of oesophageal manometric abnormalities in patients with non-cardiac chest pain with more certainty, it is desirable to perform oesophageal manometry in a group of patients with known ischaemic heart disease. We were therefore interested to hear that Dr Alban Davies and his colleagues have found normal manometric …