Goldman L, et al., eds. Esophageal spasm 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. Troponin elevations tend to be mild, with more indolent (or even flat) troponin trajectories. In general, renal failure in the absence of symptoms/signs of ischemia is best classified as a non-MI troponin elevation. Gibson, C.M. Four patients staffed by one full-time nurse; 4. 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 include: food and drink, such as red wine or spicy food. However, when using hsTn assays, a rising (or falling) pattern may be seen as early as one hour after myocardial injury.4 Importantly, the phenomenon of cTn release is independent of mechanismthus, cardiomyocyte necrosis of any kindischemic, infectious, toxic, or otherwiseis not infrequently detectable. Disclaimer. 2, pp. From 1 to 4 percent of patients ultimately proven to have acute coronary syndrome are sent home from the emergency department.24 Patients with acute coronary syndrome who are sent home without further evaluation are more likely to be women, to be nonwhite, to present without chest pain, or to have ECGs that are normal or show nonspecific changes.18, A suggested approach to the evaluation of patients with chest pain or symptoms consistent with acute coronary syndrome is provided in Figure 1. 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. 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. 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. Epub 2015 Oct 27. Very high levels of troponin typically indicate that a person has had a heart attack, which can occur if the blood supply to some of the heart muscle suddenly 13, no. https://www.uptodate.com/contents/search. Most low-risk patients may undergo early exercise testing or can be discharged with careful outpatient follow-up. 104, no. In conclusion, there is a high prevalence of GERD in patients with CAD. 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 This may represent a stricture or spasm related to reflux. Y. Liu, S. He, Y. Chen et al., Acid reflux in patients with coronary artery disease and refractory chest pain, Internal Medicine, vol. 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). Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder with increasing prevalence worldwide. When is a troponin elevation an acute myocardial infarction? Copyright 2015 Chui Man Carmen Hui et al. Of 218 episodes of ST-segment depression, 45 (20.6%) correlated with pathologic reflux. 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, Iser, D.M., et al., Prospective study of cardiac troponin I release in patients with upper gastrointestinal bleeding. A 12-lead ECG should be obtained within 10 minutes of presentation in patients with ongoing chest pain. Bookshelf Most high-risk patients should be hospitalized. The likelihood of acute coronary syndrome (low, intermediate, high) should be determined in all patients who present with chest pain. Troponin is a protein found in all muscles. 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. The characteristics of common ECG abnormalities in specific anatomic locations are presented in Table 2.11. Troponin: Elevated troponin levels can indicate heart damage or even a heart attack. The growing use of hsTn assays will no doubt lead to more frequent detection of elevated cTn values, thus the topic is timely. When is a troponin elevation an acute myocardial infarction? Myoglobin is a low-molecular-weight protein that is present in both cardiac and skeletal muscle. 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]. 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]. 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. Vedovati, and G. Agnelli, Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. 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. If a spasm lasts long enough, you can have chest pain (angina) and even a heart attack. 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]. Elevated cTn in asymptomatic CKD is common, the frequency which is dependent on the assay (cTnT > cTnI) and cut-off value used. A violet-colored or dusky red rash develops, most commonly on your face and eyelids and on your knuckles, elbows, knees, chest and back. Compared to patients without GERD, patients with GERD were found to have significantly higher number of ST-segment depression episodes and total ischemic burden. The physical examination in patients with acute coronary syndrome frequently is normal. cTnI was elevated in 23 patients (25%) and was normal in 70 patients (75%). The likelihood of silent ischemia traditionally has been thought to be greater in patients with diabetes. https://www.merckmanuals.com/professional/gastrointestinal-disorders/esophageal-and-swallowing-disorders/diffuse-esophageal-spasm#. (a) Right coronary artery 100% occluded in the proximal segment. 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. It is also possible that myocardial ischemia in our patient was due to esophagocardiac reflex, which describes myocardial ischemia associated with chemical esophageal stimulation. The silent myocardial infarction hypothesis is based on the relatively high incidence of ischemic changes noted on screening ECGs in patients with diabetes. Melanson, S.E., D.A. Despite multiple mechanisms suggested to explain its pathophysiology, there is increasing evidence that supports direct neuroadrenergic myocardial stimulation with concomitant transient, reversible, coronary vasospasm as the inciting event, either at the epicardial or arteriolar level. Physical exam did not reveal evidence of heart failure, wheezing, or crackles. But sometimes the spasms are frequent and can prevent food and liquids from traveling through the esophagus. CJC Open. In a single-center study by Salvador et al., 30 patients with GERD underwent simultaneous 24-hour multichannel intraluminal impedance pH monitoring and continuous O2 saturation monitoring via pulse oximetry [8]. 8600 Rockville Pike Esophageal spasms are sometimes associated with conditions such as heartburn or gastroesophageal reflux disease (GERD). Federal government websites often end in .gov or .mil. Esophageal spasms - Diagnosis and treatment - Mayo Clinic The squeezing chest pain associated with esophageal spasms also can be caused by a heart attack. 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. eCollection 2022 Aug. Life (Basel). The benefit of its use was a significant reduction in hospital admissions of patients who did not have acute coronary syndrome.26 However, a subsequent study27 suggested that this benefit is not seen unless physicians have been trained in the use of the instrument. High-sensitivity troponin tests can detect elevated troponin levels in people without symptoms of cardiovascular disease, according to a 2019 study. Troponin elevation in CKD is worth discussion, as the interpretation of elevation of cTn in non-ACS patients may be difficult. Elevated cTn in asymptomatic CKD is common, the frequency which is dependent on the assay (cTnT > cTnI) and cut-off value used. The feeling that an object is stuck in your throat. A 71-year-old male with a history of coronary artery disease presented to the ED with complaints of acute chest pain and respiratory Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. 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). For our patient, high dose of PPI was initiated to control his reflux symptoms along with further optimization of medical therapy for his CAD in order to augment efforts at secondary prevention of future ischemic events. However, elevated troponin doesnt always mean cardiac damage. However, patient declined the elective EGD on his follow-up visit as he had no further episodes of nocturnal dyspnea on higher doses of antireflux medication. Your email address will not be published. Esophageal Troponin T or I generally is the most sensitive determinant of acute coronary syndrome, although the MB isoenzyme of creatine kinase also is used. Transmural myocardial ischemia results in ST-segment elevation with the vector shifted toward the involved epicardial layer, and without treatment typically results in STEMI. Cardiac Tn is elevated in up to 18% of patients with AAD,8 indicative of the high acuity of illness than specific to aortic dissection itself, although coronary artery occlusion in this setting is well-described.9 Misdiagnosis of AAD may potentially result in incorrect administration of anticoagulation therapy, or lead to a risky delay in the correct diagnosis.10, Another common non-ACS cause of chest pain and cTn elevation is pulmonary embolism (PE).11 The frequency of elevated cTn is 10-50% in such patients,12-13 and may be related to a combination of acute right ventricular strain and injury, hypoxia and tachycardia. The authors also demonstrated significant improvement in ST-segment depression episodes and total ischemic burden following a 7-day course of proton pump therapy (PPI) in patients with GERD suggesting that restoring normal esophageal pH might eliminate acid-derived esophagocardiac reflex and hence myocardial ischemia [11]. 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)). Becattini, C., M.C. 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]. Epub 2017 Aug 1. The likelihood of acute infarction is 1.1 percent or less with a normal ECG and 2.6 percent or less with nonspecific ECG changes.10, The ECG provides information that assists in stratifying the patients risk of having acute coronary syndrome, establishing the diagnosis, and determining the treatment strategy. The presentation is variable and can mimic other conditions such as aortic dissection, pulmonary embolism, and myocardial infarction (MI). 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]. 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. Rapezzi, C., et al., Risk factors for diagnostic delay in acute aortic dissection. Serum markers such as aspartate transaminase, lactate dehydrogenase, and lactate dehydrogenase subforms no longer are used because they lack cardiac specificity and their delayed elevation precludes early diagnosis.9 Characteristics of the most important serum cardiac markers are summarized in Table 3.1619. Identifying the cause and effect relationship between respiratory symptoms and GERD has been a clinical challenge. 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. 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. 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. This is of course problematic, as the incidence and prevalence of coronary artery disease and ACS is high in this population. 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Ilva, T.J., et al., The etiology and prognostic significance of cardiac troponin I elevation in unselected emergency department patients. 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. 14446, Lippincott-Raven, Philadelphia, Pa, USA, 4th edition, 2009. 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 Storrow, A.B., et al., Discordant cardiac biomarkers: frequency and outcomes in emergency department patients with chest pain. spasm Accessed Oct. 6, 2020. Cureus. If esophageal spasms interfere with your ability to eat or drink, treatments are available. Kim MN, Kim HL, Park SM, Shin MS, Yu CW, Kim MA, Hong KS, Shim WJ. Jensen, J.K., et al., Frequency and significance of troponin T elevation in acute ischemic stroke. spontaneous), and bradyarrhythmias. 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. 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). 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. The saphenous venous grafts to the diagonal and circumflex artery were chronically occluded with evidence of collaterals. Chest-wall tenderness reduces the likelihood of acute coronary syndrome (-LR: 0.2).3. HHS Vulnerability Disclosure, Help It is important to remember that an MI specifically refers to myocardial injury due to acute myocardial ischemia to the myocardium. 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. Accessed Oct. 6, 2020. Coronary vasospasm as a possible cause of elevated cardiac Acute Coronary Syndromes The symptoms lasted for an hour and he was taken to the hospital due to persistent discomfort. doi: 10.7759/cureus.26193. Differentiating acute coronary syndrome from noncardiac chest pain is the primary diagnostic challenge. Merck Manual Professional Version. CR524CR529, 2004. 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. Typical GERD symptoms are heartburn and regurgitation of food contents. PMC Various mechanisms for HF-related cTn elevation have been proposed, including subendocardial ischemia from wall tension, apoptosis, spontaneous necrosis, as well as inflammation.