Effect of citalopram on chest pain in patients with functional chest pain

Chest pain can be divided in cardiac or non-cardiac chest pain (NCCP). To
establish the diagnosis NCCP, acute coronary disease has to be ruled out first.
NCCP can be caused by functional chest pain (FCP). NCCP in the absence of
musculoskeletal abnormalities, major esophageal motor disorders,
gastroesophageal reflux or eosinophilic esophagitis is called FCP. The
pathophysiology is not fully understood. Most likely multiple factors play a
role, such as esophageal hypersensitivity and enhanced perception. Citalopram
and other antidepressants are proven to be effective in the treatment of
functional gastrointestinal disorders such as irritable bowel syndrome.
However, available data regarding low dose antidepressants in functional chest
pain is inconclusive. Moreover, all current evidence concerning the effect of
low dose antidepressants in patients with functional chest pain is extracted
from trials that pooled patients with different functional esophageal
disorders.

To assess the effect of citalopram on symptoms of chest pain in patients with
functional chest pain.

A single center, double-blind placebo-controlled randomized trial.

During the study period of twelve weeks, patients will either receive daily 20
mg of citalopram or a placebo.

Citalopram has been studied extensively in the past decades, mainly for its use
in major depressive disorders. Citalopram is an antidepressant in the group of
selective serotonin reuptake inhibitors (SSRIs). In addition to its effect as
antidepressant the effect of citalopram in functional gastrointestinal
disorders such irritable bowel disease has also been proven. Citalopram and
other SSRIs are frequently being prescribed off-label in the same dosage in
patients with functional chest pain making the risk of this study negligible
over routine clinical care. 20 mg of citalopram is a low dose, so only minor
side effects are being expected.

The burden for the participating patients consists of one extra visit to the
hospital, 2 phone calls, filling-out questionnaires at the start, after 6 weeks
and at the end of the study, and filling-out a daily symptom diary.
Stopping therapy without tapering off the antidepressant may result in
withdrawal symptoms such as headaches, nausea, sweating or insomnia. The chance
of developing withdrawal symptoms is higher after long term use of
antidepressants. Since we only treat the patients for twelve weeks, we estimate
this as low risk. However, patients will be instructed to contact the
investigators when these symptoms occur after ceasing treatment.

In conclusion, citalopram and other SSRIs are already being used off-label in
patients with functional chest pain, however a randomized controlled trial
never has been done. Therefore there is no additional risk for patients
participating in this study compared to daily clinical practice. No additional
investigations are needed before patients can participate since all
investigations are already done as part of clinical routine