After presenting our case, we review the literature on this atypical presentation of GERD causing acute coronary syndrome and discuss potential mechanisms. With older conventional assays, cTnI or T is typically measurable as early as 3-4 hours following myocardial injury. Current Surgical Therapy. The likelihood of silent ischemia traditionally has been thought to be greater in patients with diabetes. High troponin levels can be a sign of a heart attack or other heart damage. Heart Vessels. government site. reported similar findings of longer duration and higher incidence of ischemic events in patients with CAD and gastric reflux [12]. Esophageal spasms are sometimes associated with conditions such as heartburn or gastroesophageal reflux disease (GERD). WebGastrointestinal causes (eg, gastroesophageal reflux, esophageal spasm, peptic ulcer, pancreatitis, biliary disease) Musculoskeletal causes (eg, costochondritis, cervical radiculopathy) Psychiatric disorders. 150160, 2006. The rash, which can be itchy and painful, is often the first sign of dermatomyositis. Some people may mistake it for heart pain, also called angina. Esophageal spasms are painful contractions within the muscular tube connecting your mouth and stomach. 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. P. Liuzzo and J. 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. The initial assessment requires a focused history (including risk factor analysis), a physical examination, an electrocardiogram (ECG) and, frequently, serum cardiac marker determinations (Table 1).1, Chest or left arm pain or discomfort as chief symptom, Abnormal ST segments or T waves not documented to be new, T-wave flattening or inversion of T waves in leads with dominant R waves, Symptoms of acute coronary syndrome include chest pain, referred pain, nausea, vomiting, dyspnea, diaphoresis, and light-headedness. These small Q waves are known as septal Q waves because of the origin of the initial vector in ventricular depolarization. During the hospitalization, the patient had another episode of nocturnal dyspnea with chest tightness. Despite the value of cTn for ACS diagnosis, risk stratification and management, it has become quite evident that non-ACS elevation of the marker is not uncommon. Thus, it is critically important to recognize this association and initiate treatment with PPIs in appropriate patients with CAD and concomitant GERD as it might improve GERD and prevent future adverse cardiac events. Kott KA, Bishop M, Yang CHJ, Plasto TM, Cheng DC, Kaplan AI, Cullen L, Celermajer DS, Meikle PJ, Vernon ST, Figtree GA. He also denied any nausea, vomiting, or epigastric discomfort. Compared to patients without GERD, patients with GERD were found to have significantly higher number of ST-segment depression episodes and total ischemic burden. A patient whose presenting symptoms include acute chest discomfort, acute ST-T wave changes, and a rise in troponin would be suspected of having a type 1 NSTEMI. (a) Smooth short stricture in the distal esophagus slightly proximal to the gastroesophageal junction. Imaging evidence of new loss of viable myocardium, significant reversible perfusion defect on nuclear imaging, or new regional wall motion abnormality in a pattern consistent with an ischemic etiology. However, a combination of atypical symptoms improves identification of low-risk patients. In patients with acute coronary syndrome with elevated cTnI and insignificant coronary artery disease, the possibility of coronary vasospasm as a cause of elevated cTnI should be considered. (b) Multiple tertiary contractions of the distal esophagus suggestive of dysmotility. 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Esophageal spasms are divided into two categories: Diffuse esophageal spasms : These usually make a person regurgitate food or drink. One study5 found the syndrome in 22 percent of 596 patients who presented to emergency departments with sharp or stabbing pain. 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. WebTroponin is a protein enzyme that leaks from the heart when this muscle is damaged. Pain radiating to the shoulder, left arm, or both arms somewhat increases the likelihood of acute coronary syndrome (likelihood ratio [LR]: 1.6).3, Typical angina is described as pain that is substernal, occurs on exertion, and is relieved with rest. Cardiopulmonary resuscitation (CPR): Due to physical injury to the heart from mechanical chest compressions and from electrical shocks of external defibrillation. high-risk TIMI or GRACE scores, or markedly elevated troponin levels. A. Chauhan, P. A. Mullins, G. Taylor, M. C. Petch, and P. M. Schofield, Cardioesophageal reflex: a mechanism for linked angina in patients with angiographically proven coronary artery disease, Journal of the American College of Cardiology, vol. The feeling that an object is stuck in your throat. For example, hypertensive emergency, severe aortic valve stenosis, hypertrophic cardiomyopathy, and tachyarrhythmias (including atrial fibrillation with rapid ventricular response) may cause increased myocardial oxygen demand, and in patients with underlying CAD, could precipitate a type 2 MI. Assessment of coronary spasms with transluminal attenuation gradient in coronary computed tomography angiography. Sepsis without shock: Direct toxicity of circulating cytokines to cardiac myocytes. WebIn patients with acute coronary syndrome with elevated cTnI and insignificant coronary artery disease, the possibility of coronary vasospasm as a cause of elevated cTnI WebThe diagnosis of esophageal spasm is used quite freely among physicians, including gastroenterologists. Diagnosing a type 2 MI requires evidence of acute myocardial ischemia (Figure 2) with an elevated troponin but must also have at least one of the following:2. Chauhan et al. Peroral endoscopic myotomy for esophageal motility disorders. An exercise treadmill test for patients without abnormal findings on the initial tests, or a nuclear stress test or echocardiographic stress test; 6. Cardiol J. The https:// ensures that you are connecting to the This content does not have an Arabic version. Your email address will not be published. 9, pp. 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). Event monitoring and continuous ST-segment monitoring; 2. History of diabetes mellitus is associated with elevated cardiac troponin I levels in patients with chest pain but no coronary heart disease. Unable to load your collection due to an error, Unable to load your delegates due to an error. Distinguishing the diagnose of type 2 MI vs. non-MI troponin elevation depends on documenting whether there are ancillary ischemic symptoms, ECG findings, imaging, and/or cath findings of acute myocardial ischemia. Cureus. Diffuse esophageal spasm (corkscrew esophagus). Wang CH, Cherng WJ, Meng HC, Hong MJ, Kuo LT. Echocardiography. Although CK commonly was measured serially (along with CK-MB) at the time of hospital admission and six to 12 hours after admission, this marker largely has been replaced by cardiac troponins and CK-MB.9,16, CK-MB is much more cardiac specific than CK alone, and is useful for the early diagnosis of acute myocardial infarction.9 CK-MB typically is detectable in the serum four to six hours after the onset of ischemia, peaks in 12 to 24 hours, and normalizes in two to three days. Hospitalists encounter troponin elevations daily, but we have to use clinical judgment to determine if the troponin elevation represents either a myocardial infarction (MI), or a non-MI troponin elevation (i.e. Common examples of underlying causes of non-MI troponin elevation include: Some underlying conditions can cause a type 2 MI or a non-MI troponin elevation depending on the clinical context. Common examples of underlying causes of type 2 MI include acute blood loss anemia (e.g. Cardiac markers (troponin T, troponin I, and/or creatine kinaseMB isoenzyme of creatine kinase) should be measured in any patient who has chest pain consistent with acute coronary syndrome. However, the CK-MB subform assay is not yet widely available. Patients with all three of these features have a greater likelihood of having acute coronary syndrome than patients with none, one, or even two of these features. However, in a patient presenting with other or vague complaints where an elevated troponin was found amongst a battery of tests, a type 2 MI may be favored, particularly if there is evidence of an underlying trigger for a supply-demand mismatch. Please enable it to take advantage of the complete set of features! Difficulty swallowing solids and liquids, sometimes related to swallowing specific substances. 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]. It is important to remember that an MI specifically refers to myocardial injury due to acute myocardial ischemia to the myocardium. Serum cardiac marker determinations play a vital role in the diagnosis of acute myocardial infarction. Furthermore, CK levels may be elevated in a number of noncardiac conditions, including trauma, seizures, renal insufficiency, hyperthermia, and hyperthyroidism. Task Force 5: coronary artery disease. In the future, advanced diagnostic modalities, such as myocardial perfusion imaging, may have a role in reducing unnecessary hospitalizations. 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. Goldman L, et al., eds. In the setting of irreversible myocardial cell injury, the contents of the cTn complex are released into circulation. Accessed Oct. 6, 2020. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). Symptoms of acute myocardial ischemia such as typical chest pain. The term NSTEMI should be used only when referring to a type 1 MI not when referring to a type 2 MI.1. S. Dobrzycki, A. Baniukiewicz, J. Korecki et al., Does gastro-esophageal reflux provoke the myocardial ischemia in patients with CAD? International Journal of Cardiology, vol. Physical exam did not reveal evidence of heart failure, wheezing, or crackles. Squeezing pain in your chest. Background: Spasms may cause minor to J Am Coll Cardiol. Esophageal neuromuscular function and motility disorders. A healthy esophagus usually moves food into your stomach through a series of coordinated muscle contractions. 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. Esophageal rupture is a rare but potentially fatal cause of chest pain. 20 Patients with a normal CK-MB level but De Borba, and A. A violet-colored or dusky red rash develops, most commonly on your face and eyelids and on your knuckles, elbows, knees, chest and back. Maeder, M., et al., Sepsis-associated myocardial dysfunction: diagnostic and prognostic impact of cardiac troponins and natriuretic peptides. 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. The prevalence of GERD ranged from 11% to 38.8% worldwide per Map of Digestive Disorders & Disease (MDD) with Mexico, Spain, Malaysia, and Yemen at the top quartile of prevalence, and Asian countries in the lowest quartile [1]. Patients at intermediate risk may be monitored in a telemetry bed in an inpatient setting or a chest pain unit. These include: food and drink, such as red wine or spicy food. 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. 2023 American College of Cardiology Foundation. It is also possible that myocardial ischemia in our patient was due to esophagocardiac reflex, which describes myocardial ischemia associated with chemical esophageal stimulation. 6772, 2005. The administration of i/v or per-oral nitroglycerin relieves the symptoms of pain which does not happen if the patient has gastrointestinal diseases.The esophageal 70, no. 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). This tube is called the esophagus. 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. Careers. Before one concludes that an abnormal cTnI level is a false-positive result, the possibility of coronary vasospasm should be considered. This content does not have an English version. He had no further ischemic episodes after increasing the dose of antireflux medication over a 6-month follow-up. The likelihood of acute coronary syndrome (low, intermediate, high) should be determined in all patients who present with chest pain. Esophageal spasms are sometimes associated with conditions such as heartburn or gastroesophageal reflux disease (GERD). 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. Your healthcare provider may also order tests like an electrocardiogram if there is concern for heart damage from COVID-19 or chest X-rays to monitor for any lung damage. 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. Januzzi, J.L., Jr, et al., High-Sensitivity Troponin T Concentrations in Acute Chest Pain Patients Evaluated With Cardiac Computed Tomography. Vedovati, and G. Agnelli, Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. Elevated cTn values outside of ACS are not uncommon and reflect cardiomyocyte necrosis from a wide array of cardiac, pulmonary and systemic diseases. However, they appear to be related to atypical functioning of nerves that control the muscles you use when you swallow. 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. The term acute coronary syndrome is useful because the initial presentation and early management of unstable angina, STEMI, and NSTEMI frequently are similar. Furthermore, the prevalence of GERD in patients with CAD is higher, with some studies reporting prevalence ranging from 40% to 78% [4]. Epub 2017 Aug 1. a , nonischemic myocardial injury). 2020; doi:10.1007/s10388-019-00693-w. Castell DO. The esophagus is a muscular tube that connects your mouth and your stomach. Liu et al. (See "Diagnosis of acute myocardial infarction", Ohlmann, P., et al., Diagnostic and prognostic value of circulating D-Dimers in patients with acute aortic dissection. While at the hospital, the patient experienced a similar episode of nocturnal dyspnea, prompting a barium esophagram, which was suggestive of a stricture in the distal esophagus from long-standing GERD. cTnI was elevated in 23 patients (25%) and was normal in 70 patients (75%). Stroke/intracranial hemorrhage: Mechanisms of myocardial injury and troponin elevation are incompletely understood, but may include catecholamine surges that injure the heart. Ominous physical findings include a new mitral regurgitation murmur, hypotension, pulmonary rales, a new third heart sound (S3 gallop), and new jugular venous distention. High-sensitivity troponin tests can detect elevated troponin levels in people without symptoms of cardiovascular disease, according to a 2019 study. In USA, approximately 7 million people are affected [2]. 1, pp. 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 The term NSTEMI served as a catch-all term to describe both type 1 NSTEMIs and type 2 MIs, but that classification system is no longer valid. Pain from esophageal spasm is one distinct possibility for precipitating ischemia in this patient. The pain is often intense, and you might mistake it for heart pain, also known as angina. This widely available marker has low sensitivity and specificity for cardiac damage. Barium esophagram demonstrated a smooth short narrowing in the distal esophagus proximal to the gastroesophageal junction, suggesting a stricture or spasm from yet controlled reflux disease (Figures 2(a) and 2(b)). Distinguishing a type 1 NSTEMI from a type 2 MI depends mainly on the clinical context and clinical judgment. It is underappreciated that GERD can potentially cause myocardial ischemia by increasing myocardial oxygen demand or by decreasing myocardial oxygen supply (esophagocardiac reflex). The patient was stabilized with resolution of nocturnal symptoms and he was discharged home with plan to perform an outpatient upper EGD to evaluate for reflux and esophagitis. 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. Troponin: Elevated troponin levels can indicate heart damage or even a heart attack. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Furthermore, the high prevalence of O2 desaturation was found mostly in GERD patients with primary respiratory complaints [8]. Bouzas-Mosquera A, Peteiro J, Broulln FJ, Constanso IP, Rodrguez-Garrido JL, Martnez D, Yez JC, Bescos H, lvarez-Garca N, Vzquez-Rodrguez JM. 15, no. Acute coronary syndrome encompasses a spectrum of coronary artery diseases, including unstable angina, ST-elevation myocardial infarction (STEMI; often referred to as Q-wave myocardial infarction), and non-STEMI (NSTEMI; often referred to as nonQ-wave myocardial infarction). NSTEMI (acute coronary artery plaque rupture/erosion), Supply/demand mismatch (heterogeneous underlying causes), Sudden cardiac death with ECG evidence of acute myocardial ischemia before cardiac troponins could be drawn, MI due to percutaneous coronary intervention (PCI), MI due to coronary artery bypass grafting (CABG). 11, pp. However, these same conditions could cause a non-MI troponin elevation in patients without CAD and could also cause myocardial injury and troponin release by causing acute left ventricular stretch/strain. Reproduction of previous documented angina, Known history of coronary artery disease, including myocardial infarction, New transient mitral regurgitation, hypotension, diaphoresis, pulmonary edema or rales, New or presumably new transient ST-segment deviation (> 0.05 mV) or T-wave inversion (> 0.2 mV) with symptoms, Elevated cardiac troponin T or I, or elevated CK-MB, ST-segment elevation greater in lead III than in lead II, ST-segment elevation of > 2.5 mm in lead V, ST-segment depression of > 1 mm in leads II, III, and aVF, ST-segment depression of 1 mm or ST-segment elevation in leads II, III, and aVF, Measured 4 hours after onset of chest pain, Measured 10 hours after onset of chest pain. Esophageal spasms typically occur only occasionally and might not need treatment. 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. Copyright 2015 Chui Man Carmen Hui et al. WebTroponin levels may remain high for 1 to 2 weeks after a heart attack. Although protocols for chest pain units may vary somewhat, one protocol28 that has been shown to be safe and cost-effective in an intermediate-risk population consists of the following: 1. eCollection 2022 Jun. Two mechanisms have been proposed to be responsible for respiratory symptoms induced by gastric reflux: (1) vagal reflex response from stimulation of the vagus nerve by gastric acidic content, resulting in bronchoconstriction and (2) microaspiration of gastric contents causing direct irritation or trauma to the upper airway [57]. ESRD patients who present with volume overload due to missed dialysis also typically have a non-MI troponin elevation. Unauthorized use of these marks is strictly prohibited. 16211628, 1996. 854861, 2009. Type 2 MI is defined as "myocardial infarction secondary to ischaemia due to either increased oxygen demand or decreased supply, e.g. Lauer, B., et al., Cardiac troponin T in patients with clinically suspected myocarditis. Atypical symptoms do not necessarily rule out acute coronary syndrome. Rings of muscle contract and relax to allow food and liquids to pass through the upper and lower portions. Troponin is a protein found in all muscles. Esophageal spasms are painful contractions within the muscular tube connecting your mouth and stomach. Biomarker Development in Cardiology: Reviewing the Past to Inform the Future. 26th ed. https://www.merckmanuals.com/professional/gastrointestinal-disorders/esophageal-and-swallowing-disorders/diffuse-esophageal-spasm#. 5, pp. Of those with a positive cTn, 42.7% of the patients did not have ACS.3. Stein, R., et al., Prognostic implications of normal (<0.10 ng/ml) and borderline (0.10 to 1.49 ng/ml) troponin elevation levels in critically ill patients without acute coronary syndrome. Use of this type of systematic approach has the potential to improve the ability of physicians to care for patients with possible acute coronary syndrome, as well as reduce the likelihood of medical error. The presentation is variable and can mimic other conditions such as aortic dissection, pulmonary embolism, and myocardial infarction (MI). Swinkels, B.M., et al., Prevalence and clinical significance of an elevated cardiac troponin I in patients presenting to the Emergency Department without chest pain. R. S. Irwin and J. M. Madison, Diagnosis and treatment of chronic cough due to gastro-esophageal reflux disease and postnasal drip syndrome, Pulmonary Pharmacology & Therapeutics, vol. Acute (on chronic) systolic or diastolic heart failure: Usually due to acute ventricular wall stretch/strain. In the absence of evidence of shock and symptoms/signs of myocardial ischemia, do not document type 2 MI. 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 Accessed Oct. 6, 2020. Pain may be referred to either arm, the jaw, the neck, the back, or even the abdomen. Risk stratification then should be performed using the criteria in Table 1.1 Alternatively, the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument can be used.26 This is a computerized decision-making program that is built into the ECG machine. 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.
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