32, no. 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. When there is only elevated troponin levels (or even a rise and fall in troponin) without new symptoms or ECG/imaging evidence of myocardial ischemia, it is most appropriate to document a non-MI troponin elevation due to a nonischemic mechanism of myocardial injury. Your email address will not be published. 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. Esophageal spasms are painful contractions within the muscular tube connecting your mouth and stomach. A. Valiati, Extraesophageal manifestations of gastroesophageal reflux disease, Jornal Brasileiro de Pneumologia, vol. 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. 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. Distinguishing a type 1 NSTEMI from a type 2 MI depends mainly on the clinical context and clinical judgment. Esophageal spasms are sometimes associated with conditions such as heartburn or gastroesophageal reflux disease (GERD). Coronary Vasospastic Angina: A Review of the Pathogenesis, Diagnosis, and Management. 27, no. During the hospitalization, the patient had another episode of nocturnal dyspnea with chest tightness. Thompson PD, Klocke FJ, Levine BD, Van Camp SP. Of 218 episodes of ST-segment depression, 45 (20.6%) correlated with pathologic reflux. eCollection 2022 Jun. The following day, the patient underwent a barium esophagram for evaluation of his symptoms, as an esophagogastroduodenoscopy (EGD) was deferred given recent NSTEMI. 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. Pericarditis and myocarditis: Due to direct injury from myocardial inflammation. 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. 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). GERD is caused by an impaired antireflux barrier and defective lower esophageal sphincter, leading to reflux of gastric acid into the esophagus. Isolated small Q waves in leads II, III, and aVF (in the electrically vertical heart) and leads I and aVL (in the electrically horizontal heart) frequently are normal. Jensen, J.K., et al., Frequency and significance of troponin T elevation in acute ischemic stroke. eCollection 2022 Aug. Life (Basel). Although GERD classically presents with symptoms of heartburn and regurgitation of food contents, some patients may present with less typical extraesophageal cardiac or respiratory symptoms. WebGiven extensive prior cardiac history, anginal equivalent symptoms, ischemic ECG changes, and elevated troponin I levels, non-ST elevation myocardial infarction PMC WebIn this report we show that coronary arterial and esophageal spasm are sometimes clinically indistinguishable. 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). However, a combination of atypical symptoms improves identification of low-risk patients. J. P. Liuzzo and J. Event monitoring and continuous ST-segment monitoring; 2. Esophageal rupture is a rare but potentially fatal cause of chest pain. 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. Stress-induced (takotsubo) cardiomyopathy: Stress-induced release of neurohormonal factors and catecholamines that cause direct myocyte injury and transient dilatation of the ventricle. Heart Vessels. Troponin elevations tend to be mild, with more indolent (or even flat) troponin trajectories. 3, pp. The site is secure. Patients at intermediate risk may be monitored in a telemetry bed in an inpatient setting or a chest pain unit. University of Florida, Gastroesophageal Reflux Disease, Office of Medical Informatics. Bookshelf The cardiac troponins typically are measured at emergency department admission and repeated in six to 12 hours. 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 Before one concludes that an abnormal cTnI level is a false-positive result, the possibility of coronary vasospasm should be considered. See permissionsforcopyrightquestions and/or permission requests. Bethesda, MD 20894, Web Policies coronary artery spasm, The predictive value of the ECG varies markedly, depending on the baseline risk (pretest probability) for coronary artery disease in a given patient. It is important to remember that an MI specifically refers to myocardial injury due to acute myocardial ischemia to the myocardium. Upon presentation to the Emergency Department, he denied any chest discomfort, palpitations, dizziness, orthopnea, or lower extremity swelling. Park JY, Kang EJ, Kim MH, Yong HS, Rha SW. PLoS One. 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. This investigation enrolled 93 patients who presented to the emergency department with suspected coronary ischemia and had insignificant coronary artery disease. 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. Storrow, A.B., et al., Discordant cardiac biomarkers: frequency and outcomes in emergency department patients with chest pain. The likelihood of acute coronary syndrome (low, intermediate, high) should be determined in all patients who present with chest pain. The diagnosis of a type 1 MIs (STEMI and NSTEMI) is supported by the presence of an acute coronary thrombus or plaque rupture/erosion on coronary angiography or a strong suspicion for these when angiography is unavailable or contraindicated. 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. https://www.uptodate.com/contents/search. 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. 1, pp. Pain may be referred to either arm, the jaw, the neck, the back, or even the abdomen. Esophageal (a) Smooth short stricture in the distal esophagus slightly proximal to the gastroesophageal junction. Accessed Oct. 6, 2020. Peroral endoscopic myotomy for esophageal motility disorders. Shave, R., et al., Exercise-Induced Cardiac Troponin Elevation: Evidence, Mechanisms, and Implications. Elsevier; 2020. https://www.clinicalkey.com. Sometimes an antidepressant, such as imipramine (Tofranil), may be prescribed. Symptoms of acute myocardial ischemia such as typical chest pain. The results of cTn testing often guide the decision for coronary intervention. 13, no. The esophagus is a muscular tube that connects your mouth and your stomach. COPD exacerbation), shock states (cardiogenic, hypovolemic, hemorrhagic, or septic), coronary vasospasm (e.g. Pain from esophageal spasm is one distinct possibility for precipitating ischemia in this patient. Eur J Intern Med. 13th ed. Background: Abnormal levels of serum cardiac troponin I (cTnI) are occasionally found in patients presenting with acute coronary syndromes but having insignificant coronary artery disease. Before one concludes that an abnormal cTnI level is a false-positive result, the possibility of coronary vasospasm should be considered. However, many patients with GERD may present with extraesophageal symptoms such as chest pain or discomfort mimicking angina, chronic cough, wheezing, dyspnea, globus sensation, hoarseness, or recurrent pneumonia as their primary presentation [57]. MeSH CR524CR529, 2004. Cardiopulmonary resuscitation (CPR): Due to physical injury to the heart from mechanical chest compressions and from electrical shocks of external defibrillation. Over the previous five to six years, the patient experienced recurring episodes of nocturnal coughing and difficulty breathing during his sleep which was typically precipitated after intake of a heavy meal. 4, pp. Cardiac troponin (cTn) is the standard blood-based test to confirm the diagnosis of acute myocardial infarction. K. R. DeVault, Extraesophageal symptoms of GERD, Cleveland Clinic Journal of Medicine, vol. 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? In USA, approximately 7 million people are affected [2]. Your provider might recommend a proton pump inhibitor to treat GERD. Admission 12-lead surface electrocardiogram (ECG) revealed normal sinus rhythm with 1-2mm horizontal ST depressions in V3 to V5, which resolved within one hour. 2016 Mar;28:59-64. doi: 10.1016/j.ejim.2015.10.004. A more recent article on acute coronary syndrome is available. Coronary vasospasm, documented by an ergonovine provocation test, was found in 38 patients (41%). 9, pp. When is a troponin elevation an acute myocardial infarction? 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. 14446, Lippincott-Raven, Philadelphia, Pa, USA, 4th edition, 2009. If esophageal spasms interfere with your ability to eat or drink, treatments are available. 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. They happen only 8600 Rockville Pike 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 Of those with a positive cTn, 42.7% of the patients did not have ACS.3. In the future, advanced diagnostic modalities, such as myocardial perfusion imaging, may have a role in reducing unnecessary hospitalizations. This content does not have an English version. 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 The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Some kinds of troponin are only found in the heart muscle. 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. The term acute coronary syndrome is useful because the initial presentation and early management of unstable angina, STEMI, and NSTEMI frequently are similar. 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. Vedovati, and G. Agnelli, Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). Lauer, B., et al., Cardiac troponin T in patients with clinically suspected myocarditis. The https:// ensures that you are connecting to the WebTroponin is a protein enzyme that leaks from the heart when this muscle is damaged. Pain patterns can be identical, nitroglycerin can bring relief, interval electrocardiograms and exercise electrocardiograms generally disclose no abnormalities, coronary arteriograms may be within normal limits or nearly so, and, 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. In acute coronary syndrome, common electrocardiographic abnormalities include T-wave tenting or inversion, ST-segment elevation or depression (including J-point elevation in multiple leads), and pathologic Q waves. Velmahos, G.C., et al., Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder in the western industrial world. 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. Intermediate-risk patients should undergo a structured evaluation, often in a chest pain unit. Feng J, et al. 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. Kim MN, Kim HL, Park SM, Shin MS, Yu CW, Kim MA, Hong KS, Shim WJ. An official website of the United States government. 11th ed. Acute (on chronic) systolic or diastolic heart failure: Usually due to acute ventricular wall stretch/strain. The pain is often intense, and you might mistake it for heart pain, also known as angina. 150160, 2006. An 83-year-old Italian male presented with sudden onset of dyspnea associated with cough and diaphoresis that woke him up from sleep at midnight. Troponin: Elevated troponin levels can indicate heart damage or even a heart attack. Myoglobin should be used in conjunction with other serum markers, because its level peaks and falls rapidly in patients with ischemia. 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. Relationship between dobutamine echocardiography and the elevation of cardiac troponin I in patients with acute coronary syndromes. There are two types of esophageal spasms distal esophageal spasm and hypercontractile esophagus, also referred to as jackhammer esophagus. Patients with NSTE-ACS who have had previous PCI or 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. Esophageal spasms are painful contractions within the muscular tube connecting your mouth and stomach. 2022 Jul 8;17(7):e0271189. Epub 2015 Oct 27. Subsequently, patient underwent an early invasive strategy of cardiac catheterization and angiography that revealed chronic, severe, native 3-vessel CAD (Figures 1(a) and 1(b)). 2020; doi:10.1007/s10388-019-00693-w. Castell DO. 5, pp. 16211628, 1996. Januzzi, and R.H. Christenson, Increases of cardiac troponin in conditions other than acute coronary syndrome and heart failure. Current Surgical Therapy. 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. Diffuse esophageal spasm (corkscrew esophagus). Federal government websites often end in .gov or .mil. 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]. 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. Troponin is a protein found in all muscles. If a spasm lasts long enough, you can have chest pain (angina) and even a heart attack. Unlike troponin I levels, troponin T levels may be elevated in patients with renal disease, polymyositis, or dermatomyositis. (See "Diagnosis of acute myocardial infarction", 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. Troponin levels typically start to elevate in the circulation within 2 to 3 hours of the onset of chest pain. The growing use of hsTn assays will no doubt lead to more frequent detection of elevated cTn values, thus the topic is timely. His home medications included esomeprazole, lisinopril, metoprolol succinate, aspirin, clopidogrel, and ezetimibe. GERD may also lead to demand ischemia and cause NSTEMI through other mechanisms. The presentation is variable and can mimic other conditions such as aortic dissection, pulmonary embolism, and myocardial infarction (MI). 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. Would you like email updates of new search results? Iser, D.M., et al., Prospective study of cardiac troponin I release in patients with upper gastrointestinal bleeding. Chui Man Carmen Hui and Santosh K. Padala contributed equally to the paper and share first authorship. Serum cardiac marker determinations play a vital role in the diagnosis of acute myocardial infarction. In a recent study examining 69,299 patients admitted through the emergency department(ED), 48% had their cTn measured.