Esophageal Rupture Presenting with ST 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. Renal failure (acute kidney injury or chronic kidney disease): Multiple etiologies, but at least partially related to reduced renal clearance of troponin. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. eCollection 2022. government site. Thygesen, K., et al., Universal definition of myocardial infarction. After presenting our case, we review the literature on this atypical presentation of GERD causing acute coronary syndrome and discuss potential mechanisms. 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). Y. Liu, S. He, Y. Chen et al., Acid reflux in patients with coronary artery disease and refractory chest pain, Internal Medicine, vol. Careers. Copyright 2000-2023 by the Society of Hospital Medicine and related companies. amyloidosis), systemic hypertension, left ventricular hypertrophy, HF, pulmonary hypertension and chronic kidney disease (CKD).28. Scholl, F.G., et al., Interval or permanent nonoperative management of acute type A aortic dissection. In: Goldman-Cecil Medicine. Physical exam did not reveal evidence of heart failure, wheezing, or crackles. 150160, 2006. In type 2 MI, myocardial injury occurs secondary to an underlying process, and therefore requires correct documentation of the underlying cause as well. Mohammed, A.A. and J.L. Before 2022 Jul 27;12(8):1124. doi: 10.3390/life12081124. However, they appear to be related to atypical functioning of nerves that control the muscles you use when you swallow. This medicine may help reduce the sensation of pain in the Relationship between dobutamine echocardiography and the elevation of cardiac troponin I in patients with acute coronary syndromes. 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. Acute pulmonary embolism: Result of acute right ventricular wall stretch/strain, not from myocardial ischemia. J Am Coll Cardiol. Muscle weakness. Januzzi, J.L., Jr, et al., High-Sensitivity Troponin T Concentrations in Acute Chest Pain Patients Evaluated With Cardiac Computed Tomography. Furthermore, the high prevalence of O2 desaturation was found mostly in GERD patients with primary respiratory complaints [8]. Gibson, C.M. Can Troponin Elevation Mean Something Other than History of diabetes mellitus is associated with elevated cardiac troponin I levels in patients with chest pain but no coronary heart disease. 6772, 2005. Chest-wall tenderness reduces the likelihood of acute coronary syndrome (-LR: 0.2).3. Ilva, T.J., et al., The etiology and prognostic significance of cardiac troponin I elevation in unselected emergency department patients. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for Damage to the heart causes troponin to be released into the bloodstream. 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, Esophageal spasm Furthermore, the prevalence of GERD in patients with CAD is higher, with some studies reporting prevalence ranging from 40% to 78% [4]. Diseases of the esophagus. Esophageal spasms can feel like sudden, severe chest pain that lasts from a few minutes to hours. Assessment of coronary spasms with transluminal attenuation gradient in coronary computed tomography angiography. Your email address will not be published. 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]. the Management of Patients With CJC Open. Peroral endoscopic myotomy for esophageal motility disorders. Cardiac Troponin Elevations in Patients Without Acute Liu et al. Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder with increasing prevalence worldwide. Compared to patients without GERD, patients with GERD were found to have significantly higher number of ST-segment depression episodes and total ischemic burden. Troponin: What Is it, Tests, and More - Healthline 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. 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. 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 Furthermore, Swiatowski et al. Accessed Oct. 6, 2020. Aviles, R.J., et al., Troponin T Levels in Patients with Acute Coronary Syndromes, with or without Renal Dysfunction. Early markers of acute ischemia include myoglobin and creatine kinaseMB subforms (or isoforms), when available. 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 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. Difficulty swallowing solids and liquids, sometimes related to swallowing specific substances. How to Interpret Elevated Cardiac Troponin Levels | Circulation 261266, 2002. These include: food and drink, such as red wine or spicy food. 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. 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. All rights reserved. This tube is called the esophagus. Elevated cTn values outside of ACS are not uncommon and reflect cardiomyocyte necrosis from a wide array of cardiac, pulmonary and systemic diseases. One study5 found the syndrome in 22 percent of 596 patients who presented to emergency departments with sharp or stabbing pain. This lack of blood supply can be due to an acute absolute or relative deficiency in coronary artery blood flow. It's not clear what causes esophageal spasms. 2016;23(2):149-54. doi: 10.5603/CJ.a2015.0072. high-risk TIMI or GRACE scores, or markedly elevated troponin levels. Typical GERD symptoms are heartburn and regurgitation of food contents. The characteristics of common ECG abnormalities in specific anatomic locations are presented in Table 2.11. He was diagnosed with non-ST elevation myocardial infarction based on the electrocardiographic changes and cardiac biomarker elevation. Kline, J.A., et al., Surrogate markers for adverse outcomes in normotensive patients with pulmonary embolism. ESRD patients who present with volume overload due to missed dialysis also typically have a non-MI troponin elevation. Clipboard, Search History, and several other advanced features are temporarily unavailable. There are two types of esophageal spasms distal esophageal spasm and hypercontractile esophagus, also referred to as jackhammer esophagus. Esophageal spasms typically occur only occasionally and might not need treatment. doi: 10.1371/journal.pone.0271189. Troponins (T, I, C) are found in striated and cardiac muscle. Stress-induced (takotsubo) cardiomyopathy: Stress-induced release of neurohormonal factors and catecholamines that cause direct myocyte injury and transient dilatation of the ventricle. Event monitoring and continuous ST-segment monitoring; 2. Accessed Oct. 6, 2020. 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. Advertising revenue supports our not-for-profit mission. A more recent article on acute coronary syndrome is available. Lauer, B., et al., Cardiac troponin T in patients with clinically suspected myocarditis. 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. 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. No assessment protocol or constellation of tests is totally accurate in diagnosing acute coronary syndrome. In a recent study examining 69,299 patients admitted through the emergency department(ED), 48% had their cTn measured. A more recent article on acute coronary syndrome is available. 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. The symptoms lasted for an hour and he was taken to the hospital due to persistent discomfort. Normal troponin levels: Healthy ranges and what high levels mean WebIn this report we show that coronary arterial and esophageal spasm are sometimes clinically indistinguishable. 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 predictive value of the ECG varies markedly, depending on the baseline risk (pretest probability) for coronary artery disease in a given patient. In a study12 of 775 consecutive patients with chest pain who were admitted to a cardiac care unit, acute myocardial infarction was diagnosed in 10 percent of patients with normal ECG findings (11 of 107 patients) in the emergency department, 8 percent of patients with minimal changes (six of 73 patients), and 41 percent of patients with frankly abnormal ECG findings (245 of 595 patients). Esophageal spasms are divided into two categories: Diffuse esophageal spasms : These usually make a person regurgitate food or drink. Myoglobin is a low-molecular-weight protein that is present in both cardiac and skeletal muscle. If esophageal spasms interfere with your ability to eat or drink, treatments are available. Bethesda, MD 20894, Web Policies In general, the prevalence of cTn elevation in the general population is low when currently available assays are used. 104, no. 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]. Esophageal The feeling that an object is stuck in your throat. 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 Coronary artery spasm 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. Esophageal neuromuscular function and motility disorders. Coronary vasospasm can be elicited by stimulation of alpha-adrenergic, histaminic, Importantly, an elevated cTn in the absence of ACS is most often associated with a worse prognosis and should not be disregarded as a false positive result. The term NSTEMI should be used only when referring to a type 1 MI not when referring to a type 2 MI.1. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. The growing use of hsTn assays will no doubt lead to more frequent detection of elevated cTn values, thus the topic is timely. Only about 2 percent of patients with cocaine-associated chest pain have acute coronary syndrome.4. Sometimes an antidepressant, such as imipramine (Tofranil), may be prescribed. Patients with elevated cTnI levels, compared with those with normal cTnI, were older (63 +/- 13 y vs 56 +/- 14 y, P =.032), had a higher incidence of males (78% vs 52%, P =.049) and positive ergonovine provocation tests (74% vs 30%, P <.0001), and tended to have a lower incidence of hypercholesterolemia (26% vs 48%, P =.088) and normal electrocardiograms (48% vs 70%, P =.078). Federal government websites often end in .gov or .mil. ISSN 1553-085X. If the LES doesn't work properly, you can get heartburn or acid indigestion. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). Coronary Vasospastic Angina: A Review of the Pathogenesis, Diagnosis, and Management. 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. 11, pp. 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. Task Force 5: coronary artery disease. Troponin: Elevated troponin levels can indicate heart damage or even a heart attack. Diagnosis of Acute Coronary Syndrome | AAFP (b) Left anterior descending with 99% ostial and 100% mid occlusion and circumflex 99% distal occlusion. 2016 Mar;28:59-64. doi: 10.1016/j.ejim.2015.10.004. Serum cardiac marker determinations play a vital role in the diagnosis of acute myocardial infarction. Accessed Oct. 6, 2020. Velmahos, G.C., et al., Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. 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. 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. Before one concludes that an abnormal cTnI level is a false-positive result, the possibility of coronary vasospasm should be considered. 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. 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. Elsevier; 2020. https://www.clinicalkey.com. Goldman L, et al., eds. Methods and results: During the hospitalization, the patient had another episode of nocturnal dyspnea with chest tightness. 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. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. Pain may be referred to either arm, the jaw, the neck, the back, or even the abdomen. University of Florida College of Medicine, 2012. Elevated CK-MB may be further characterized into subforms (or isoforms). 52, no. 2022 Jul 8;17(7):e0271189. They happen only 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. In the setting of irreversible myocardial cell injury, the contents of the cTn complex are released into circulation. The following day, the patient underwent a barium esophagram for evaluation of his symptoms, as an esophagogastroduodenoscopy (EGD) was deferred given recent NSTEMI. In challenging cases, cardiology consultation can help determine the MI type and/or the next diagnostic and treatment considerations. A 71-year-old male with a history of coronary artery disease presented to the ED with complaints of acute chest pain and respiratory The return of food and liquids back up your esophagus, also called regurgitation. 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. The pain is often intense, and you might mistake it for heart pain, also known as angina. GERD may also lead to demand ischemia and cause NSTEMI through other mechanisms. But sometimes the spasms are frequent and can prevent food and liquids from traveling through the esophagus. CR524CR529, 2004. Squeezing pain in your chest. 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. 2001 Oct;18(7):573-9. doi: 10.1046/j.1540-8175.2001.00573.x. 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. This investigation enrolled 93 patients who presented to the emergency department with suspected coronary ischemia and had insignificant coronary artery disease. 2010 December 15, 2009 [cited 2010 August 3]; Available from: Kelley, W.E., J.L. elevated troponin 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. Patients with NSTE-ACS who have had previous PCI or Storrow, A.B., et al., Discordant cardiac biomarkers: frequency and outcomes in emergency department patients with chest pain. Feldman M, et al., eds. Cells. 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. 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. 16211628, 1996. Spasms may cause minor to Wang CH, Cherng WJ, Meng HC, Hong MJ, Kuo LT. Echocardiography. With older conventional assays, cTnI or T is typically measurable as early as 3-4 hours following myocardial injury. 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. 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. Coronary vasospasm as a possible cause of elevated cardiac Esophageal rupture is a rare but potentially fatal cause of chest pain. 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. Acute (on chronic) systolic or diastolic heart failure: Usually due to acute ventricular wall stretch/strain. Transmural myocardial ischemia results in ST-segment elevation with the vector shifted toward the involved epicardial layer, and without treatment typically results in STEMI. The term acute coronary syndrome is useful because the initial presentation and early management of unstable angina, STEMI, and NSTEMI frequently are similar. 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. If you experience squeezing chest pain, seek immediate medical care. 10, no. 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. 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. Cardiol J. This study investigated whether coronary vasospasm could be a reason for elevated cTnI in this patient population. 2020; doi:10.1007/s10388-019-00693-w. Castell DO. 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]. High-sensitivity troponin tests can detect elevated troponin levels in people without symptoms of cardiovascular disease, according to a 2019 study. He remained symptom-free until 6-month follow-up visit. 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]. Your email address will not be published. Upon presentation to the Emergency Department, he denied any chest discomfort, palpitations, dizziness, orthopnea, or lower extremity swelling. Esophageal spasms are painful contractions within the muscular tube connecting your mouth and stomach. The squeezing chest pain associated with esophageal spasms also can be caused by a heart attack. Esophageal spasms are painful contractions within the muscular tube connecting your mouth and stomach. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). 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. 2023 American College of Cardiology Foundation. 32, no. 15, no. Current Surgical Therapy. Elsevier; 2020. https://www.clinicalkey.com. 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. Distinguishing a type 1 NSTEMI from a type 2 MI depends mainly on the clinical context and clinical judgment. 8600 Rockville Pike 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. The likelihood of acute coronary syndrome (low, intermediate, high) should be determined in all patients who present with chest pain. A. Valiati, Extraesophageal manifestations of gastroesophageal reflux disease, Jornal Brasileiro de Pneumologia, vol. 11651171, 2013. Cameron AM, et al. Of these, 2,344 patients (3.3% overall, or 7.0% of those that had a cTn measured) had an elevated cTn concentration. The lab has to be taken in the context of the patients presentation and other supporting findings. COPD exacerbation), shock states (cardiogenic, hypovolemic, hemorrhagic, or septic), coronary vasospasm (e.g. 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. This widely available marker has low sensitivity and specificity for cardiac damage. 27, no. WebTroponin is a protein enzyme that leaks from the heart when this muscle is damaged. Abnormal levels of serum cardiac troponin I (cTnI) are occasionally found in patients presenting with acute coronary syndromes but having insignificant coronary artery disease. Based on the coronary anatomy the patient was managed conservatively with optimal medical therapy with no plan for percutaneous intervention or revascularization.