We present a case of an atypical presentation of GERD leading to NSTEMI, likely from demand ischemia in the setting of known severe 3-vessel native CAD as well as chronic total occlusions of venous grafts. 7, pp. 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]. Goldman L, et al., eds. 27, no. The exact mechanism by which cTn release occurs in this setting remains unknown but may be due to right ventricular injury.32. Y. Liu, S. He, Y. Chen et al., Acid reflux in patients with coronary artery disease and refractory chest pain, Internal Medicine, vol. Measurement of troponins I and T and/or CK-MB at admission and six to eight hours after admission; 3. 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. 5, pp. Pericarditis and myocarditis: Due to direct injury from myocardial inflammation. Rings of muscle contract and relax to allow food and liquids to pass through the upper and lower portions. Accessed Oct. 6, 2020. Various mechanisms for HF-related cTn elevation have been proposed, including subendocardial ischemia from wall tension, apoptosis, spontaneous necrosis, as well as inflammation. National Library of Medicine If a spasm lasts long enough, you can have chest pain (angina) and even a heart attack. and J.J. van de Leur, Elevated troponin T concentrations in critically ill patients. 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 2001 Oct;18(7):573-9. doi: 10.1046/j.1540-8175.2001.00573.x. 2022 Jul 27;12(8):1124. doi: 10.3390/life12081124. You may also feel pain in the right side of the chest alone. Bouzas-Mosquera A, Peteiro J, Broulln FJ, Constanso IP, Rodrguez-Garrido JL, Martnez D, Yez JC, Bescos H, lvarez-Garca N, Vzquez-Rodrguez JM. His home medications included esomeprazole, lisinopril, metoprolol succinate, aspirin, clopidogrel, and ezetimibe. However, they appear to be related to atypical functioning of nerves that control the muscles you use when you swallow. Identifying the cause and effect relationship between respiratory symptoms and GERD has been a clinical challenge. One study5 found the syndrome in 22 percent of 596 patients who presented to emergency departments with sharp or stabbing pain. Because the cardiac and skeletal muscle isoforms of troponin T and I differ, they are known as the cardiac troponins. They are the preferred markers for the diagnosis of myocardial injury.24 Troponin T and I generally have similar sensitivity and specificity for the detection of myocardial injury. 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. ISSN 1553-085X. The troponins also can help identify low-risk patients who may be sent home with close follow-up.17 In a study17 of 773 patients presenting to an emergency department with acute chest pain, those with a normal or nearly normal ECG and a normal troponin I test six hours after admission had a very low risk of major cardiac events (0.3 percent) during the next 30 days. Significant Q waves (greater than 0.04 seconds in duration and at least one quarter of the height of the corresponding R wave) suggest myocardial infarction. However, in a prospective observational study6 of 528 patients with symptoms suggestive of coronary artery disease on presentation to the emergency department of a cardiac referral center, symptoms did not differ significantly in patients with and without diabetes. K. R. DeVault, Extraesophageal symptoms of GERD, Cleveland Clinic Journal of Medicine, vol. Upon presentation to the Emergency Department, he denied any chest discomfort, palpitations, dizziness, orthopnea, or lower extremity swelling. Accessibility Merck Manual Professional Version. Bastiany A, Pacheco C, Sedlak T, Saw J, Miner SES, Liu S, Lavoie A, Kim DH, Gulati M, Graham MM. This medicine may help reduce the sensation of pain in the These small Q waves are known as septal Q waves because of the origin of the initial vector in ventricular depolarization. Careers. The following day, the patient underwent a barium esophagram for evaluation of his symptoms, as an esophagogastroduodenoscopy (EGD) was deferred given recent NSTEMI. A chest pain unit is a specialized unit within an emergency department or a medical center; the unit is dedicated to careful monitoring and aggressive implementation of diagnostic protocols (clinical guidelines) for the evaluation of acute coronary syndrome. 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. He was diagnosed with non-ST elevation myocardial infarction based on the electrocardiographic changes and cardiac biomarker elevation. Approximately 60% of the reflux episodes were associated with oxygen desaturation. The results of cTn testing often guide the decision for coronary intervention. Distinguishing a type 1 NSTEMI from a type 2 MI depends mainly on the clinical context and clinical judgment. This content does not have an Arabic version. (See "Diagnosis of acute myocardial infarction", Unable to load your collection due to an error, Unable to load your delegates due to an error. 2016;23(2):149-54. doi: 10.5603/CJ.a2015.0072. Copyright 2000-2023 by the Society of Hospital Medicine and related companies. Accessed Oct. 6, 2020. Furthermore, CK levels may be elevated in a number of noncardiac conditions, including trauma, seizures, renal insufficiency, hyperthermia, and hyperthyroidism. Elevated cTn is strongly associated with mortality in acute PE; in a meta-analysis of 20 acute PE studies, patients with an elevated cTn had more than 5-fold increase in mortality (19.7% vs. 3.7%).14, Other relevant cardiac diagnoses that may present with both chest pain and elevated cTn include post-revascularization myocardial injury states, myocarditis (where cTn elevations are common and prognostically meaningful),15-16 acute pericarditis,17 and blunt force trauma to the heart.18, In the context of life-threatening illness, the prevalence of elevated cTn is considerable (table 1). Mohammed, A.A. and J.L. The presentation is variable and can mimic other conditions such as aortic dissection, pulmonary embolism, and myocardial infarction (MI). Esophageal neuromuscular function and motility disorders. Relationship between dobutamine echocardiography and the elevation of cardiac troponin I in patients with acute coronary syndromes. 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. 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? 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. 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. We hypothesized that he had myocardial ischemia due to increased oxygen demand from uncontrolled GERD symptoms. The return of food and liquids back up your esophagus, also called regurgitation. The symptoms lasted for an hour and he was taken to the hospital due to persistent discomfort. Serum cardiac marker determinations play a vital role in the diagnosis of acute myocardial infarction. 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. Patients at intermediate risk may be monitored in a telemetry bed in an inpatient setting or a chest pain unit. Melanson, S.E., D.A. It is important to remember that an MI specifically refers to myocardial injury due to acute myocardial ischemia to the myocardium. Unauthorized use of these marks is strictly prohibited. The CK-MB mass assay is more sensitive than the CK-MB activity assay.20, Like the CK level, the peak CK-MB level does not predict infarct size; however, it can be used to detect early reinfarction.16 Serial CK-MB levels commonly are obtained at admission to the emergency department and are repeated in six to 12 hours, depending on the assay that is used.20. Esophageal spasms are sometimes associated with conditions such as heartburn or gastroesophageal reflux disease (GERD). Ilva, T.J., et al., The etiology and prognostic significance of cardiac troponin I elevation in unselected emergency department patients. Measurement of cardiac troponin (cTn) has revolutionized the evaluation and management of patients with suspected acute coronary syndrome (ACS). Diseases of the esophagus. The likelihood of silent ischemia traditionally has been thought to be greater in patients with diabetes. Jensen, J.K., et al., Frequency and significance of troponin T elevation in acute ischemic stroke. Storrow, A.B., et al., Discordant cardiac biomarkers: frequency and outcomes in emergency department patients with chest pain. If esophageal spasms interfere with your ability to eat or drink, treatments are available. 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. Unlike troponin I levels, troponin T levels may be elevated in patients with renal disease, polymyositis, or dermatomyositis. Of those with a positive cTn, 42.7% of the patients did not have ACS.3. The growing use of hsTn assays will no doubt lead to more frequent detection of elevated cTn values, thus the topic is timely. Cardiol J. 11, pp. doi: 10.7759/cureus.26193. Troponin elevation in CKD is worth discussion, as the interpretation of elevation of cTn in non-ACS patients may be difficult. Accuracy is enhanced when the ECG is obtained in a patient with ongoing chest pain. ESRD patients who present with volume overload due to missed dialysis also typically have a non-MI troponin elevation. spontaneous), and bradyarrhythmias. Coronary Vasospastic Angina: A Review of the Pathogenesis, Diagnosis, and Management. 2022 Jun 22;14(6):e26193. Chauhan et al. 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. 26th ed. Damage to the heart causes troponin to be released into the bloodstream. The cardiac troponins typically are measured at emergency department admission and repeated in six to 12 hours. WebTroponin levels may remain high for 1 to 2 weeks after a heart attack. Esophageal spasms typically occur only occasionally and might not need treatment. FOIA 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. 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. If the test result is elevated (in a range that indicates damage to heart tissue), this can mean that the patient had a heart attack very recently. 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. WebIn this report we show that coronary arterial and esophageal spasm are sometimes clinically indistinguishable. 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. A coronary artery spasm is a temporary tightening (constriction) of the muscles in the wall of an artery that sends blood to the heart. Kott KA, Bishop M, Yang CHJ, Plasto TM, Cheng DC, Kaplan AI, Cullen L, Celermajer DS, Meikle PJ, Vernon ST, Figtree GA. Elsevier; 2020. https://www.clinicalkey.com. The pain is often intense, and you might mistake it for heart pain, also known as angina. 2020; doi:10.1007/s10388-019-00693-w. Castell DO. 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. 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. 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. Renal failure (acute kidney injury or chronic kidney disease): Multiple etiologies, but at least partially related to reduced renal clearance of troponin. The presentation is variable and can mimic other conditions such as aortic dissection, pulmonary embolism, and myocardial infarction (MI). The term NSTEMI should be used only when referring to a type 1 MI not when referring to a type 2 MI.1. Based on the coronary anatomy the patient was managed conservatively with optimal medical therapy with no plan for percutaneous intervention or revascularization. government site. 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). The rash, which can be itchy and painful, is often the first sign of dermatomyositis. All rights reserved. 854861, 2009. demonstrated that esophageal acid stimulation in patients with documented CAD on angiogram resulted in typical chest discomfort and a significant reduction in coronary blood flow as measured by intracoronary Doppler in 9 of 14 (64%) patients [10]. 150160, 2006. Furthermore, the prevalence of GERD in patients with CAD is higher, with some studies reporting prevalence ranging from 40% to 78% [4]. Troyanov, S., et al., Diagnostic specificity and prognostic value of cardiac troponins in asymptomatic chronic haemodialysis patients: a three year prospective study. WebCauses of elevated troponin STEMI: ST elevation myocardial infarction; NSTEMI: non-ST elevation myocardial infarction; PCI: percutaneous coronary intervention; SLE: systemic lupus erythematosus; BSA: body surface area. 6772, 2005. 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. The magnitude of an ECG abnormality affects diagnostic accuracy. doi: 10.1371/journal.pone.0271189. An exercise treadmill test for patients without abnormal findings on the initial tests, or a nuclear stress test or echocardiographic stress test; 6. 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. Difficulty swallowing solids and liquids, sometimes related to swallowing specific substances. This tube is called the esophagus. This lack of blood supply can be due to an acute absolute or relative deficiency in coronary artery blood flow. (b) Multiple tertiary contractions of the distal esophagus suggestive of dysmotility. 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. Some people may mistake it for heart pain, also called angina. Patients with type 2 MI often have a history of fixed obstructive coronary disease, which when coupled with the acute trigger facilitates the type 2 MI; however, underlying CAD is not always present. During the hospitalization, the patient had another episode of nocturnal dyspnea with chest tightness. Diagnosis requires an electrocardiogram and a careful review for signs and symptoms of cardiac ischemia. 14446, Lippincott-Raven, Philadelphia, Pa, USA, 4th edition, 2009. Cardio-esophageal neural reflex arcs have been described in humans. 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. Cardiac catheterization revealed chronic three-vessel coronary artery disease, with 2 patent grafts and 2 chronically occluded grafts. Epub 2017 Aug 1. MeSH 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)). Januzzi, J.L., Jr, et al., High-Sensitivity Troponin T Concentrations in Acute Chest Pain Patients Evaluated With Cardiac Computed Tomography. Advertising revenue supports our not-for-profit mission. WebGastrointestinal causes (eg, gastroesophageal reflux, esophageal spasm, peptic ulcer, pancreatitis, biliary disease) Musculoskeletal causes (eg, costochondritis, cervical radiculopathy) Psychiatric disorders. 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. 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 feeling that an object is stuck in your throat. The most common signs and symptoms include: Skin changes. 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].