CJC Open. All Rights Reserved. Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder with increasing prevalence worldwide. Sometimes an antidepressant, such as imipramine (Tofranil), may be prescribed. Diffuse esophageal spasm (corkscrew esophagus). Cardiac catheterization revealed chronic three-vessel coronary artery disease, with 2 patent grafts and 2 chronically occluded grafts. When used by trained physicians, the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (a computerized, decision-making program built into the electrocardiogram machine) results in a significant reduction in hospital admissions of patients who do not have acute coronary syndrome. GERD is caused by an impaired antireflux barrier and defective lower esophageal sphincter, leading to reflux of gastric acid into the esophagus. FOIA Stress-induced (takotsubo) cardiomyopathy: Stress-induced release of neurohormonal factors and catecholamines that cause direct myocyte injury and transient dilatation of the ventricle. (c) Sequential vein graft to right posterolateral and posterior descending artery with 40% proximal disease. Subendocardial ischemia classically results in ST-segment depression and T-wave inversion.14 Approximately 25 percent of patients with ST-segment depression and elevated creatine kinaseMB isoenzyme (CK-MB) levels eventually develop STEMI, and 75 percent have NSTEMI. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. Squeezing pain in your chest. PMC Elsevier; 2020. https://www.clinicalkey.com. This is an open access article distributed under the, http://www.worldgastroenterology.org/assets/downloads/pdf/wdhd/2008/events/map_of_digestive_disorders_2008.pdf, http://www.niddk.nih.gov/health-information/health-statistics/Pages/digestive-diseases-statistics-for-the-united-states.aspx. The term acute coronary syndrome encompasses a range of thrombotic coronary artery diseases, including unstable angina and both ST-segment elevation and nonST-segment elevation myocardial infarction. The levels will continue to rise at that time until a peak is reached, generally between 12 and 48 hours. Based on Marriotts criteria,15 epicardial injury is diagnosed when the J point (origin of the ST segment at its junction with the QRS complex) is (1) elevated by 1 mm or more in two or more limb leads or precordial leads V4 to V6 or by 2 mm or more in two or more precordial leads V1 to V3; or is (2) depressed by 1 mm or more in two or more precordial leads V1 to V3. J Am Coll Cardiol. Although the ECG may be completely normal in a patient with myocardial ischemia and evolving infarction, classic ECG changes occur in STEMI.14 Within minutes, there is J-point elevation, and tall, peaked, hyperacute T waves develop; ST-segment elevation and reciprocal-lead ST-segment depression also occur. Patients at intermediate risk may be monitored in a telemetry bed in an inpatient setting or a chest pain unit. If the LES doesn't work properly, you can get heartburn or acid indigestion. In the future, advanced diagnostic modalities, such as myocardial perfusion imaging, may have a role in reducing unnecessary hospitalizations. Combining a doubling of the baseline myoglobin level at two hours after symptom onset with an abnormal myoglobin test at six hours after symptom onset increases the sensitivity to 95 percent at six hours.25. Esophageal Rupture Presenting with ST Segment Elevation and Junctional Rhythm Mimicking Acute Myocardial Infarction Esophageal rupture is a rare but potentially fatal cause of chest pain. The cardiac troponins typically are measured at emergency department admission and repeated in six to 12 hours.20 Patients with a normal CK-MB level but elevated troponin levels are considered to have sustained minor myocardial damage or microinfarction, whereas patients with elevations of both CK-MB and troponins are considered to have had acute myocardial infarction. Association of epicardial adipose tissue with coronary spasm and coronary atherosclerosis in patients with chest pain: analysis of data collated by the KoRean wOmen'S chest pain rEgistry (koROSE). History of diabetes mellitus is associated with elevated cardiac troponin I levels in patients with chest pain but no coronary heart disease. The most common signs and symptoms include: Skin changes. Measurement of cardiac troponin (cTn) has revolutionized the evaluation and management of patients with suspected acute coronary syndrome (ACS). WebEsophageal spasms are problems with muscles in your esophagus, the tube that takes food and drink to your stomach after you swallow. Ominous physical findings include a new mitral regurgitation murmur, hypotension, pulmonary rales, a new third heart sound (S3 gallop), and new jugular venous distention. A more recent article on acute coronary syndrome is available. 854861, 2009. eCollection 2022 Aug. Life (Basel). a , nonischemic myocardial injury). We hypothesized that he had myocardial ischemia due to increased oxygen demand from uncontrolled GERD symptoms. Furthermore, Swiatowski et al. From 1 to 4 percent of patients ultimately proven to have acute coronary syndrome are sent home from the emergency department.24 Patients with acute coronary syndrome who are sent home without further evaluation are more likely to be women, to be nonwhite, to present without chest pain, or to have ECGs that are normal or show nonspecific changes.18, A suggested approach to the evaluation of patients with chest pain or symptoms consistent with acute coronary syndrome is provided in Figure 1. Make your tax-deductible gift and be a part of the cutting-edge research and care that's changing medicine. This widely available marker has low sensitivity and specificity for cardiac damage. There are two types of esophageal spasms distal esophageal spasm and hypercontractile esophagus, also referred to as jackhammer esophagus. Importantly, even minimally elevated cTn levels in asymptomatic, apparently healthy older adults have been shown to be associated with adverse outcomes; having elevated cTn increased the risk of all-cause and cardiovascular mortality two-fold.6, Cardiac Tn is most commonly measured for the evaluation of chest discomfort and in this context, a rising and/or falling pattern of cTn should be interpreted as being reflective of ACS. Symptoms of acute myocardial ischemia such as typical chest pain. Bethesda, MD 20894, Web Policies This content is owned by the AAFP. Furthermore, CK levels may be elevated in a number of noncardiac conditions, including trauma, seizures, renal insufficiency, hyperthermia, and hyperthyroidism. M. Swiatowski, B. Jacek, M. Klopocka et al., Suppression of gastric acid production may improve the course of angina pectoris and the results of treadmill stress test in patients with coronary artery disease, Medical Science Monitor, vol. Damage to the heart causes troponin to be released into the bloodstream. Elsevier; 2021. https://www.clinicalkey.com. Mohammed, A.A. and J.L. Linked to ventricular remodeling, elevated cTn in HF should not be discarded as false positive as the prognosis associated with elevated cTn in this setting is poor.7, An important non-ACS diagnosis to consider in a patient presenting with chest pain and elevated cTn is acute aortic dissection (AAD). Of these, 2,344 patients (3.3% overall, or 7.0% of those that had a cTn measured) had an elevated cTn concentration. A violet-colored or dusky red rash develops, most commonly on your face and eyelids and on your knuckles, elbows, knees, chest and back. Troponin elevation in CKD is worth discussion, as the interpretation of elevation of cTn in non-ACS patients may be difficult. Elevated cTn in asymptomatic CKD is common, the frequency which is dependent on the assay (cTnT > cTnI) and cut-off value used. A coronary artery spasm is a temporary tightening (constriction) of the muscles in the wall of an artery that sends blood to the heart. Risk stratification allows appropriate referral of patients to a chest pain center or emergency department, where cardiac enzyme levels can be assessed. High-sensitivity troponin tests can detect elevated troponin levels in people without symptoms of cardiovascular disease, according to a 2019 study. Troponin is a protein found in all muscles. Major disorders of esophageal hyperperistalsis: Clinical features, diagnosis and management. 2, pp. According to National Digestive Disease Information Clearinghouse (NDDIC), 20% of the population had reflux symptoms at least once a week in 2004; 8.9 million ambulatory visits in 2009 and 4.7 million hospitalizations in 2010 were attributed to GERD [3]. 2001 Oct;18(7):573-9. doi: 10.1046/j.1540-8175.2001.00573.x. Though a rise in troponin levels is often an indication of a heart attack, there are a number of other reasons why your troponin levels could be elevated. Troponin levels can be acutely elevated or chronically elevated. WebElevated troponins New or presumably new ST-segment depression High-risk findings on noninvasive stress testing Depressed LV function Hemodynamic instability Sustained V-tach PCI within previous 6 mo Prior CABG Management Dual antiplatelet therapy and antithrombotic therapy is mainstay of treatment Bookshelf and J.J. van de Leur, Elevated troponin T concentrations in critically ill patients. University of Florida College of Medicine, 2012. Furthermore, the prevalence of GERD in patients with CAD is higher, with some studies reporting prevalence ranging from 40% to 78% [4]. This lack of blood supply can be due to an acute absolute or relative deficiency in coronary artery blood flow. Various mechanisms for HF-related cTn elevation have been proposed, including subendocardial ischemia from wall tension, apoptosis, spontaneous necrosis, as well as inflammation. The test results should be available within 30 to 60 minutes, because elevated troponins are helpful in identifying the patients who benefit most from early WebGiven extensive prior cardiac history, anginal equivalent symptoms, ischemic ECG changes, and elevated troponin I levels, non-ST elevation myocardial infarction He reported regurgitation and globus sensation described as a lump in his throat with difficulty expanding his lungs. His vital signs recorded during this episode showed an abrupt rise in blood pressure to 159/85mmHg, heart rate to 96bpm, and respiratory rate to 2224 per minute, with an oxygen saturation of 98% on 2L oxygen via nasal cannula. Given this fact, and the emerging use of hsTn assays, clinicians should understand that cTn is not solely a biomarker of ischemic myocardial infarction (MI), and such clinicians must be well-versed in the differential diagnosis of an elevated cTn value outside of ACS, in order to avoid unnecessary and potentially harmful misdiagnosis and treatment for presumed ACS, while also avoiding delay in the correct treatment for the underlying cause of the elevated value. COPD exacerbation), shock states (cardiogenic, hypovolemic, hemorrhagic, or septic), coronary vasospasm (e.g. Type 2 MI is defined as "myocardial infarction secondary to ischaemia due to either increased oxygen demand or decreased supply, e.g. Medication adjustment resulted in resolution of nocturnal symptoms, which were likely a manifestation of GERD and angina. Cardiac Tn elevations have been reported in patients with snake or scorpion bites, and thought to be in part due to myocardial injury by biologic toxins, vasospasm and coagulation abnormalities.28 Elevated cTn levels have been reported to be frequently elevated in asymptomatic athletes who complete endurance exercise. A healthy esophagus usually moves food into your stomach through a series of coordinated muscle contractions. The clinician is advised to be familiar with the broad differential diagnosis of an elevated cTn, to avoid false attribution of acute MI to a patient without an ACS. CK-MB may be further characterized into subforms (or isoforms). This content does not have an Arabic version. Cardiac Tn elevations have been reported in patients with snake or scorpion bites, and thought to be in part due to myocardial injury by biologic toxins, vasospasm This is of course problematic, as the incidence and prevalence of coronary artery disease and ACS is high in this population. Scholl, F.G., et al., Interval or permanent nonoperative management of acute type A aortic dissection. Esophageal neuromuscular function and motility disorders. Januzzi, and R.H. Christenson, Increases of cardiac troponin in conditions other than acute coronary syndrome and heart failure. The benefit of its use was a significant reduction in hospital admissions of patients who did not have acute coronary syndrome.26 However, a subsequent study27 suggested that this benefit is not seen unless physicians have been trained in the use of the instrument. 11, pp. GERD may also lead to demand ischemia and cause NSTEMI through other mechanisms. Types 3-5 MI (grouped under a common ICD-10 diagnosis code for Other MI Types, or I21.A9) would rarely be diagnosed by hospitalists. This may represent a stricture or spasm related to reflux. Advertising revenue supports our not-for-profit mission. Ilva, T.J., et al., The etiology and prognostic significance of cardiac troponin I elevation in unselected emergency department patients. Given the patients extensive cardiac history and limited cardiac reserve, the physiologic response of elevated blood pressure, heart rate, respiratory rate, and transient hypoxia was likely significant enough to cause myocardial ischemia and injury. Klein Gunnewiek, J.M. Chui Man Carmen Hui and Santosh K. Padala contributed equally to the paper and share first authorship. Multivariate analysis showed that the variables independently associated with an elevated cTnI level included coronary vasospasm (odds ratio 2.41, 95% CI 1.48-3.18, P <.0001) and hypercholesterolemia (odds ratio 0.64, 95% CI 0.47-0.99, P =.049). ECG performed during this time showed ischemic changes, similar to his initial presentation. A 12-lead ECG should be obtained within 10 minutes of presentation.7. Measurement of troponins I and T and/or CK-MB at admission and six to eight hours after admission; 3. K. R. DeVault, Extraesophageal symptoms of GERD, Cleveland Clinic Journal of Medicine, vol. The silent myocardial infarction hypothesis is based on the relatively high incidence of ischemic changes noted on screening ECGs in patients with diabetes. Given extensive prior cardiac history, anginal equivalent symptoms, ischemic ECG changes, and elevated troponin I levels, non-ST elevation myocardial infarction (NSTEMI) was diagnosed and patient was started on appropriate optimal medical therapy for acute coronary syndrome. Importantly, an elevated cTn in the absence of ACS is most often associated with a worse prognosis and should not be disregarded as a false positive result. Ohlmann, P., et al., Diagnostic and prognostic value of circulating D-Dimers in patients with acute aortic dissection. This study investigated whether coronary vasospasm could be a reason for elevated cTnI in this patient population. Serial cardiac marker determinations confirm myocardial injury or infarction in more than 90 percent of patients with J-point elevation in the limb leads.9. The squeezing chest pain associated with esophageal spasms also can be caused by a heart attack. It is well known that pain can cause an increase in myocardial oxygen demand through enhanced adrenergic activity with increased heart rate and blood pressure [9]. Stroke/intracranial hemorrhage: Mechanisms of myocardial injury and troponin elevation are incompletely understood, but may include catecholamine surges that injure the heart. eCollection 2022. By definition this will be shown by an elevation of serum troponin levels in the absence of S-T segment elevation; coronary artery spasm, coronary embolism, tachy-/brady-arrhythmias, anemia, respiratory failure, hypotension, and hypertension with or without LVH Elevated serum troponin; High risk co-morbidities: Left ventricular No assessment protocol or constellation of tests is totally accurate in diagnosing acute coronary syndrome. His home medications included esomeprazole, lisinopril, metoprolol succinate, aspirin, clopidogrel, and ezetimibe. When is a troponin elevation an acute myocardial infarction? Troponins (T, I, C) are found in striated and cardiac muscle. Distinguishing a type 1 NSTEMI from a type 2 MI depends mainly on the clinical context and clinical judgment. All rights reserved. In the setting of irreversible myocardial cell injury, the contents of the cTn complex are released into circulation. Vital signs on admission revealed blood pressure of 146/95mmHg, pulse of 90bpm, respiratory rate of 18 per minute with 100% O2 saturation on 2L of oxygen via nasal cannula. Mayo Clinic College of Medicine and Science, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Graduate Medical Education, Mayo Clinic School of Continuous Professional Development, Mayo Clinic on Incontinence - Mayo Clinic Press, NEW Mayo Clinic on High Blood Pressure - Mayo Clinic Press, Mayo Clinic on Hearing and Balance - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Financial Assistance Documents Minnesota. Very high levels of troponin typically indicate that a person has had a heart attack, which can occur if the blood supply to some of the heart muscle suddenly Intermediate-risk patients should undergo a structured evaluation, often in a chest pain unit. Copyright 2005 by the American Academy of Family Physicians. Conclusions: Task Force 5: coronary artery disease. Assays for cTn, namely cTnI and cardiac troponin T (cTnT), are the preferred diagnostic tests for ACS, in particular nonST-segmentelevation myocardial infarction, because of the tissue-specific expression of cTnI and cTnT in the myocardium. Pain may be referred to either arm, the jaw, the neck, the back, or even the abdomen. 104, no. The magnitude of an ECG abnormality affects diagnostic accuracy. (a) Smooth short stricture in the distal esophagus slightly proximal to the gastroesophageal junction. Sepsis without shock: Direct toxicity of circulating cytokines to cardiac myocytes. Clipboard, Search History, and several other advanced features are temporarily unavailable. Heart Vessels. The predictive value of the ECG varies markedly, depending on the baseline risk (pretest probability) for coronary artery disease in a given patient. However, many non-ACS diagnoses should be kept in mind as potential cause for cTn elevation, Both acutely decompensated and chronic HF are associated with elevated cTn values, which may frequently be substantial. Some people may mistake it for heart pain, also called angina. A community-based sample of 3557 participants showed that the frequency of elevated cTnT using was 0.7%,5 and typically associated with risk factors for heart disease or heart failure (HF). Diseases of the esophagus. Short course of PPI not only resulted in fewer ischemic events, but also significantly improved the general health-related quality of life of patients [12]. Transmural myocardial ischemia results in ST-segment elevation with the vector shifted toward the involved epicardial layer, and without treatment typically results in STEMI. Current Surgical Therapy. Early markers of acute ischemia include myoglobin and creatine kinaseMB subforms (or isoforms), when available. While cTn elevation in CKD necessarily leads to a higher risk for false positive ACS diagnosis, cTn values in this setting are to be taken seriously; a true positive cTn related to ACS in patients with CKD is associated with a heightened risk for mortality29 compared to non CKD patients, while an asymptomatic elevation in cTn in severe CKD is associated with an increased incidence of ACS30 and a 2- to 5-fold increase in mortality.31 Serial measurement, observing for a rise and/or fall of an elevated cTn value in a patient with CKD is recommended to differentiate ACS from non-ACS causes of cTn elevations. However, patient declined the elective EGD on his follow-up visit as he had no further episodes of nocturnal dyspnea on higher doses of antireflux medication. (b) Multiple tertiary contractions of the distal esophagus suggestive of dysmotility. Only about 2 percent of patients with cocaine-associated chest pain have acute coronary syndrome.4. 5, pp. Pain from esophageal spasm is one distinct possibility for precipitating ischemia in this patient. However, there are also many mechanisms of myocardial injury unrelated to reduced coronary artery blood flow, and these should be more appropriately termed non-MI troponin elevations. Red wine or extremely hot or cold liquids are more common culprits. In conclusion, there is a high prevalence of GERD in patients with CAD. 11651171, 2013. Type 1 MI (also referred to as spontaneous MI) is generally a primary reason (or principal diagnosis) for a patients presentation to a hospital.3 Please note that a very high or rising troponin level alone is not diagnostic for a type 1 or type 2 NSTEMI. In a study12 of 775 consecutive patients with chest pain who were admitted to a cardiac care unit, acute myocardial infarction was diagnosed in 10 percent of patients with normal ECG findings (11 of 107 patients) in the emergency department, 8 percent of patients with minimal changes (six of 73 patients), and 41 percent of patients with frankly abnormal ECG findings (245 of 595 patients). Melanson, S.E., D.A. R. Salvador, T. J. Watson, F. Herbella et al., Association of gastroesophageal reflux and O2 desaturation: a novel study of simultaneous 24-h MII-pH and continuous pulse oximetry, Journal of Gastrointestinal Surgery, vol. (a) Right coronary artery 100% occluded in the proximal segment. A more recent article on acute coronary syndrome is available. https://www.merckmanuals.com/professional/gastrointestinal-disorders/esophageal-and-swallowing-disorders/diffuse-esophageal-spasm#. Cardio-esophageal neural reflex arcs have been described in humans. Myoglobin has low cardiac specificity but high sensitivity, which makes it most useful for ruling out myocardial infarction if the level is normal in the first four to eight hours after the onset of symptoms.9, Time changes in the myoglobin value also can be extremely helpful. Diagnosis requires an electrocardiogram and a careful review for signs and symptoms of cardiac ischemia. In a single-center study by Salvador et al., 30 patients with GERD underwent simultaneous 24-hour multichannel intraluminal impedance pH monitoring and continuous O2 saturation monitoring via pulse oximetry [8]. Cardiac Tn is elevated in up to 18% of patients with AAD,8 indicative of the high acuity of illness than specific to aortic dissection itself, although coronary artery occlusion in this setting is well-described.9 Misdiagnosis of AAD may potentially result in incorrect administration of anticoagulation therapy, or lead to a risky delay in the correct diagnosis.10, Another common non-ACS cause of chest pain and cTn elevation is pulmonary embolism (PE).11 The frequency of elevated cTn is 10-50% in such patients,12-13 and may be related to a combination of acute right ventricular strain and injury, hypoxia and tachycardia.
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