esophageal spasm and elevated troponin

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). Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Pulmonary Hypertension and Venous Thromboembolism, ACC Anywhere: The Cardiology Video Library, CardioSource Plus for Institutions and Practices, Annual Scientific Session and Related Events, ACC Quality Improvement for Institutions Program, National Cardiovascular Data Registry (NCDR), http://www.uptodate.com/online/content/topic.do?topicKey=chd/12606&selectedTitle=2%7E142&source=search_result, Cover Story | Structural Heart Intervention: A Peek at the Future, Feature | Hearts and the Arts: A Conversation With Barbra Streisand, New in Clinical Documents | HFpEF the Focus of New Clinical Guidance, Peripheral Matters | Inferior Vena Cava Filter Retrieval: Update on Advanced Techniques, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Pulmonary Hypertension and Venous Thromboembolism, Amyloidosis, sarcoidosis, hemochromatosis, scleroderm, Ablation, cardioversion, percutaneous intervention. NCI CPTC Antibody Characterization Program. In general, the prevalence of cTn elevation in the general population is low when currently available assays are used. Troponin: Elevated troponin levels can indicate heart damage or even a heart attack. In contrast to a type 1 MI (STEMI and NSTEMI), at type 2 MI results from an imbalance between myocardial oxygen supply and demand unrelated to acute coronary artery thrombosis or plaque rupture. Vedovati, and G. Agnelli, Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. GERD is caused by an impaired antireflux barrier and defective lower esophageal sphincter, leading to reflux of gastric acid into the esophagus. Difficulty swallowing solids and liquids, sometimes related to swallowing specific substances. 167173, 2005. 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]. Background: Studies Dr. Clemo Clinical question: Is there a difference in total thrombotic and/or bleeding events in patients with atrial fibrillation (AF) and stable coronary artery disease (CAD) on rivaroxaban Dr. Lawson Clinical question: Does point of care ultrasound (POCUS) of the internal jugular vein accurately predict central venous pressure? Bastiany A, Pacheco C, Sedlak T, Saw J, Miner SES, Liu S, Lavoie A, Kim DH, Gulati M, Graham MM. Pericarditis and myocarditis: Due to direct injury from myocardial inflammation. Troponin levels within the normal range and probability of inducible myocardial ischemia and coronary events in patients with acute chest pain. Daniels, L.B., et al., Minimally elevated cardiac troponin T and elevated N-terminal pro-B-type natriuretic peptide predict mortality in older adults: results from the Rancho Bernardo Study. One group of investigators13 found that the diagnosis of NSTEMI is greater than three times more likely in patients with chest pain whose ECG showed ST-segment depression in three or more leads or ST-segment depressions that were greater than or equal to 0.2 mV. Troponin elevation in CKD is worth discussion, as the interpretation of elevation of cTn in non-ACS patients may be difficult. Chauhan et al. Approximately 60% of the reflux episodes were associated with oxygen desaturation. ECG performed during this time showed ischemic changes, similar to his initial presentation. Most low-risk patients may undergo early exercise testing or can be discharged with careful outpatient follow-up. This content is owned by the AAFP. Accessed Oct. 6, 2020. Park JY, Kang EJ, Kim MH, Yong HS, Rha SW. PLoS One. amyloidosis), systemic hypertension, left ventricular hypertrophy, HF, pulmonary hypertension and chronic kidney disease (CKD).28. Red wine or extremely hot or cold liquids are more common culprits. Abnormal Q waves usually develop within the first day, and T-wave inversion and normalization of ST segments occur within hours to days. 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. 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. Chest pain that occurs suddenly at rest or in a young patient may suggest acute coronary vasospasm, which occurs in Prinzmetals angina or with the use of cocaine or methamphetamine. Acute (on chronic) systolic or diastolic heart failure: Usually due to acute ventricular wall stretch/strain. Elsevier; 2020. https://www.clinicalkey.com. Januzzi, and R.H. Christenson, Increases of cardiac troponin in conditions other than acute coronary syndrome and heart failure. 2, pp. Advertising revenue supports our not-for-profit mission. Feldman M, et al., eds. coronary artery spasm, Scholl, F.G., et al., Interval or permanent nonoperative management of acute type A aortic dissection. 70, no. University of Florida College of Medicine, 2012. Copyright 2015 Chui Man Carmen Hui et al. Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder with increasing prevalence worldwide. 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. Given these findings suggesting poorly controlled reflux and the possibility of esophageal dysmotility, and temporal association of his symptoms with cardiac events, the esomeprazole dose was titrated up from 20mg to 40mg for symptomatic relief. Copyright 2000-2023 by the Society of Hospital Medicine and related companies. He denied any associated palpitations, dizziness, nausea, vomiting, or epigastric abdominal pain. Velmahos, G.C., et al., Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. 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). 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]. GERD may also lead to demand ischemia and cause NSTEMI through other mechanisms. Coronary vasospasm can be elicited by stimulation of alpha-adrenergic, histaminic, Assessment of coronary spasms with transluminal attenuation gradient in coronary computed tomography angiography. Accessed Oct. 6, 2020. Of those with a positive cTn, 42.7% of the patients did not have ACS.3. The esophagus is a muscular tube that connects your mouth and your stomach. A 12-lead ECG should be obtained within 10 minutes of presentation in patients with ongoing chest pain. 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. Creatine kinase (CK) is an enzyme that is found in striated muscle and tissues of the brain, kidney, lung, and gastrointestinal tract. He remained symptom-free until 6-month follow-up visit. Esophageal spasms are sometimes associated with conditions such as heartburn or gastroesophageal reflux disease (GERD). M. J. Cousins, P. O. Bridenbaugh, D. B. Carr, and T. T. Horlocker, Neural blockade: impact on outcome, in Cousins and Bridenbaughs Neural Blockade in Clinical Anesthesia and Pain Medicine, C. L. Wu and S. S. Liu, Eds., pp. We report a case of an 83-year-old man with history of coronary artery disease and gastroesophageal reflux disease (GERD) who presented with sudden onset nocturnal dyspnea. Esophageal spasms are painful contractions within the muscular tube connecting your mouth and stomach. 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. spontaneous), and bradyarrhythmias. In a study by Dobrzycki et al., 50 patients with angiographically proven CAD underwent simultaneous continuous ECG and esophageal pH monitoring for 24 hours to assess for ST-segment depression episodes and total duration of ischemic episodes [11]. The CK-MB subform assay takes about 25 minutes to perform.21 A CK-MB2 level greater than 1 U per L in combination with a subform ratio greater than 1.5 suggests myocardial injury.9,22 One large study23 involving 1,110 patients with chest pain found that CK-MB subform analysis is 96 percent sensitive and 94 percent specific when the marker is measured six hours after symptom onset. Task Force 5: coronary artery disease. 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. 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. reported similar findings of longer duration and higher incidence of ischemic events in patients with CAD and gastric reflux [12]. The term NSTEMI should be used only when referring to a type 1 MI not when referring to a type 2 MI.1. The cTn complex is found both in the sarcomere (accounting for ~95% of cTn in the heart) as well as to a lesser extent in the cytosol of cardiomyocytes. Conclusions: Brandt, R.R., K. Filzmaier, and P. Hanrath, Circulating cardiac troponin I in acute pericarditis. 2001 Oct;18(7):573-9. doi: 10.1046/j.1540-8175.2001.00573.x. 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. 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. Patients at intermediate risk may be monitored in a telemetry bed in an inpatient setting or a chest pain unit. 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. Measurement of cardiac troponin (cTn) has revolutionized the evaluation and management of patients with suspected acute coronary syndrome (ACS). 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. 4, pp. A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Vasospastic angina, which was previously referred to as Prinzmetal [ 1] or variant angina, is characterized by episodes of rest angina that promptly respond to short-acting nitrates and are attributable to coronary artery vasospasm. WebEsophagitis oresophagealspasm Pleurisy Costochondritis Chest wall / musculoskeletal pain Gastritis Hiatal hernia Anxiety Hyperventilation syndrome Biliary colic Peptic Ulcer Other cause(please specify) None of the above/ not applicable 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. Chui Man Carmen Hui and Santosh K. Padala contributed equally to the paper and share first authorship. 13th ed. Elevation of cTn in the context of HF often occurs in the absence of coronary ischemia, and frequently occurs even in the absence of coronary artery disease. High troponin levels can be a sign of a heart attack or other heart damage. 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 (d) Left internal mammary artery graft to distal left anterior descending widely patent. Januzzi, J.L., Jr, et al., High-Sensitivity Troponin T Concentrations in Acute Chest Pain Patients Evaluated With Cardiac Computed Tomography. Your provider might recommend a proton pump inhibitor to treat GERD. Please enable it to take advantage of the complete set of features! A healthy esophagus usually moves food into your stomach through a series of coordinated muscle contractions. The exact mechanism by which cTn release occurs in this setting remains unknown but may be due to right ventricular injury.32. Most high-risk patients should be hospitalized. Cardiopulmonary resuscitation (CPR): Due to physical injury to the heart from mechanical chest compressions and from electrical shocks of external defibrillation. CJC Open. The Fourth Universal Definition of MI published in August 2018 further updated the definitions of MI (summarized in Figure 1).2 This review focuses on type 1 and type 2 MIs, which are the most common types encountered by hospitalists. Elsevier; 2020. https://www.clinicalkey.com. One study5 found the syndrome in 22 percent of 596 patients who presented to emergency departments with sharp or stabbing pain. Chest-wall tenderness reduces the likelihood of acute coronary syndrome (-LR: 0.2).3. Symptoms of acute myocardial ischemia such as typical chest pain. Squeezing pain in your chest. With older conventional assays, cTnI or T is typically measurable as early as 3-4 hours following myocardial injury. There are two types of esophageal spasms distal esophageal spasm and hypercontractile esophagus, also referred to as jackhammer esophagus. 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. Keywords: Acute Coronary Syndrome, Troponin, Biomarkers, Coronary Artery Disease, Coronary Thrombosis, Coronary Disease, Heart Failure, Hypertension, Hypertension, Pulmonary, Hypertrophy, Left Ventricular, Hypotension, Myocardial Infarction, Myocardial Ischemia, Myocarditis, Myocytes, Cardiac, Pericarditis, Pulmonary Embolism, Systemic Inflammatory Response Syndrome, Risk Factors, Chronic Disease, Tachycardia, Limit of Detection. Careers. The likelihood of acute coronary syndrome (low, intermediate, high) should be determined in all patients who present with chest pain. Horwich, T.B., et al., Cardiac Troponin I Is Associated With Impaired Hemodynamics, Progressive Left Ventricular Dysfunction, and Increased Mortality Rates in Advanced Heart Failure. 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. Admission to the cardiac care unit or a telemetry bed on the cardiology service for patients with elevated cardiac enzyme levels, recurrent chest pain consistent with unstable angina, or significant ventricular arrhythmias; 5. It is underappreciated that GERD can potentially cause myocardial ischemia by increasing myocardial oxygen demand or by decreasing myocardial oxygen supply (esophagocardiac reflex). In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. Feng J, et al. This tube is called the esophagus. Bethesda, MD 20894, Web Policies Apple, F.S., et al., Predictive value of cardiac troponin I and T for subsequent death in end-stage renal disease. WebGastrointestinal causes (eg, gastroesophageal reflux, esophageal spasm, peptic ulcer, pancreatitis, biliary disease) Musculoskeletal causes (eg, costochondritis, cervical radiculopathy) Psychiatric disorders. Eur J Intern Med. 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. Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder in the western industrial world. This investigation enrolled 93 patients who presented to the emergency department with suspected coronary ischemia and had insignificant coronary artery disease. 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). Major disorders of esophageal hyperperistalsis: Clinical features, diagnosis and management. 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. He had no further ischemic episodes after increasing the dose of antireflux medication over a 6-month follow-up. The return of food and liquids back up your esophagus, also called regurgitation. Use of this instrument in an emergency department resulted in no change in appropriate admission of patients who had acute coronary syndrome. Cureus. 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. In 1130 patients presenting to an emergency department (ED) without chest pain, the frequency of elevated cTn was 3.6% and was associated with an increased mortality.19 This prevalence increases further in population presenting with chest pain to 4.5%,20 while in critically ill patients without ACS, the frequency ranges from 27% to 55%.21, An elevation of cTn in such situations may in fact have an ischemic origin: a recent study demonstrated that an elevated hsTnT in patients without ACS was strongly associated with the presence and severity of coronary artery disease and heart muscle disease, implying that non-ACS cTn elevation may result from coronary ischemia in the absence of plaque rupture or coronary thrombosis; this situation of supply-demand mismatch is known as a Type II MI.22, Common causes of non-ACS cTn elevation in the acutely ill patients include severe hypertension or hypotension,23 severe upper gastrointestinal bleeding,24 as well as systemic inflammatory response syndrome (with or without acute respiratory distress syndrome); in each case, elevated cTn is often associated with myocardial dysfunction and worse prognosis.25 Severe central nervous system injury due to an acute stroke or head trauma may cause elevated cTn values.26 Lastly, cardiotoxic chemotherapy is well recognized to increase cTn, and when this occurs, it can help to identify a patient at risk for cardiomyopathy.27-28, A number of chronic diseases are associated with increased frequency of elevated cTn including infiltrative cardiac diseases (e.g. CK-MB may be further characterized into subforms (or isoforms). 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. After presenting our case, we review the literature on this atypical presentation of GERD causing acute coronary syndrome and discuss potential mechanisms. 16211628, 1996. The number of conditions known to cause myocardial injury through mechanisms other than myocardial ischemia (see Figure 2) is growing, especially in the current era of high-sensitivity troponin assays.4. These include: food and drink, such as red wine or spicy food. An exercise treadmill test for patients without abnormal findings on the initial tests, or a nuclear stress test or echocardiographic stress test; 6. Increased troponin levels may also be due to: Abnormally fast heartbeat; High blood pressure in lung arteries (pulmonary hypertension) Blockage of a lung artery by a blood clot, fat, or tumor cells (pulmonary embolus) Congestive heart failure; Coronary artery spasm 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]. Methods and results: Four patients staffed by one full-time nurse; 4. 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]. 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 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. The increased frequency of ischemic changes noted on screening ECGs in patients with diabetes simply may reflect their greater baseline risk of coronary artery disease. The cardiac troponins may remain elevated up to two weeks after symptom onset, which makes them useful as late markers of recent acute myocardial infarction.9. Cardiac troponin (cTn) is the standard blood-based test to confirm the diagnosis of acute myocardial infarction. F. Guarner, Lazaro, Gascon, Royo, Eximan, and Herrero, Map of Digestive Disorders and Diseases, World Gastroenterology Organization, 2008, http://www.worldgastroenterology.org/assets/downloads/pdf/wdhd/2008/events/map_of_digestive_disorders_2008.pdf. 1, pp. 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. Lauer, B., et al., Cardiac troponin T in patients with clinically suspected myocarditis. Stress-induced (takotsubo) cardiomyopathy: Stress-induced release of neurohormonal factors and catecholamines that cause direct myocyte injury and transient dilatation of the ventricle. 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 medicine may help reduce the sensation of pain in the Various mechanisms for HF-related cTn elevation have been proposed, including subendocardial ischemia from wall tension, apoptosis, spontaneous necrosis, as well as inflammation. Common examples of underlying causes of type 2 MI include acute blood loss anemia (e.g. Liu et al. 2016 Mar;28:59-64. doi: 10.1016/j.ejim.2015.10.004. Disclaimer. Cameron AM, et al. The likelihood of silent ischemia traditionally has been thought to be greater in patients with diabetes. 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. Copyright 2005 by the American Academy of Family Physicians. 2020; doi:10.1007/s10388-019-00693-w. Castell DO. Shave, R., et al., Exercise-Induced Cardiac Troponin Elevation: Evidence, Mechanisms, and Implications. Some patients may present without chest pain; in one review,2 sudden dyspnea was the sole presenting feature in 4 to 14 percent of patients with acute myocardial infarction. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Dr. Kerley Clinical question: Does initiation of empagliflozin in hospitalized patients with acute decompensated heart failure improve clinical outcomes and symptom burden? 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.

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