32, no. (See "Diagnosis of acute myocardial infarction", Copyright 2023 American Academy of Family Physicians. CK-MB2 is found in myocardial tissue, and CK-MB1 is found in plasma. Esophageal The cardiac troponins typically are measured at emergency department admission and repeated in six to 12 hours. All rights reserved. 167173, 2005. Would you like email updates of new search results? Assessment of coronary spasms with transluminal attenuation gradient in coronary computed tomography angiography. National Library of Medicine All too often, esophageal spasm is diagnosed on the basis of minor (b) Multiple tertiary contractions of the distal esophagus suggestive of dysmotility. 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. One study5 found the syndrome in 22 percent of 596 patients who presented to emergency departments with sharp or stabbing 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. Wallace, T.W., et al., Prevalence and determinants of troponin T elevation in the general population. Patients who are at high risk for acute coronary syndrome should be admitted to a coronary care unit. 4, pp. WebIn patients with acute coronary syndrome with elevated cTnI and insignificant coronary artery disease, the possibility of coronary vasospasm as a cause of elevated cTnI A healthy esophagus usually moves food into your stomach through a series of coordinated muscle contractions. 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. The same study5 demonstrated that patients presenting with sharp or stabbing pain, pleuritic pain, and positional chest pain had only a 3 percent likelihood of having acute coronary syndrome. Vedovati, and G. Agnelli, Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. Typical GERD symptoms are heartburn and regurgitation of food contents. R. R. Gurski, A. R. Pereira Da Rosa, E. Do Valle, M. A. Coronary vasospasm can be elicited by stimulation of alpha-adrenergic, histaminic, R. Salvador, T. J. Watson, F. Herbella et al., Association of gastroesophageal reflux and O2 desaturation: a novel study of simultaneous 24-h MII-pH and continuous pulse oximetry, Journal of Gastrointestinal Surgery, vol. Velmahos, G.C., et al., Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. Myoglobin is a low-molecular-weight protein that is present in both cardiac and skeletal muscle. 13, no. Risk stratification then should be performed using the criteria in Table 1.1 Alternatively, the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument can be used.26 This is a computerized decision-making program that is built into the ECG machine. Damage to the heart causes troponin to be released into the bloodstream. Multivariate analysis showed that the variables independently associated with an elevated cTnI level included coronary vasospasm (odds ratio 2.41, 95% CI 1.48-3.18, P <.0001) and hypercholesterolemia (odds ratio 0.64, 95% CI 0.47-0.99, P =.049). 8600 Rockville Pike 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. An elevated troponin T or I level is helpful in identifying patients at increased risk for death or the development of acute myocardial infarction.16 Increased risk is related quantitatively to the serum troponin level. 261266, 2002. With older conventional assays, cTnI or T is typically measurable as early as 3-4 hours following myocardial injury. A normal electrocardiogram does not rule out acute coronary syndrome. Shave, R., et al., Exercise-Induced Cardiac Troponin Elevation: Evidence, Mechanisms, and Implications. History of diabetes mellitus is associated with elevated cardiac troponin I levels in patients with chest pain but no coronary heart disease. 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. Elsevier; 2020. https://www.clinicalkey.com. 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. You may also feel pain in the right side of the chest alone. All rights reserved. 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. Aviles, R.J., et al., Troponin T Levels in Patients with Acute Coronary Syndromes, with or without Renal Dysfunction. Furthermore, the high prevalence of O2 desaturation was found mostly in GERD patients with primary respiratory complaints [8]. This is an open access article distributed under the, http://www.worldgastroenterology.org/assets/downloads/pdf/wdhd/2008/events/map_of_digestive_disorders_2008.pdf, http://www.niddk.nih.gov/health-information/health-statistics/Pages/digestive-diseases-statistics-for-the-united-states.aspx. Bedside troponin assays are being developed. Melanson, S.E., D.A. 2023 American College of Cardiology Foundation. Merck Manual Professional Version. Elevated cTn values outside of ACS are not uncommon and reflect cardiomyocyte necrosis from a wide array of cardiac, pulmonary and systemic diseases. Symptoms of acute myocardial ischemia such as typical chest pain. Januzzi, Jr., Clinical applications of highly sensitive troponin assays. University of Florida, Gastroesophageal Reflux Disease, Office of Medical Informatics. University of Florida College of Medicine, 2012. 26th Bethesda conference: recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities. 16211628, 1996. ESRD patients who present with volume overload due to missed dialysis also typically have a non-MI troponin elevation. Iser, D.M., et al., Prospective study of cardiac troponin I release in patients with upper gastrointestinal bleeding. All rights reserved. His home medications included esomeprazole, lisinopril, metoprolol succinate, aspirin, clopidogrel, and ezetimibe. 2, pp. 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). Ominous physical findings include a new mitral regurgitation murmur, hypotension, pulmonary rales, a new third heart sound (S3 gallop), and new jugular venous distention. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). SURAJ A. ACHAR, M.D., SURITI KUNDU, M.D., AND WILLIAM A. NORCROSS, M.D. We report an unusual case of an acute coronary syndrome in an elderly male as a consequence of GERD. Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder in the western industrial world. Accessed Oct. 6, 2020. Elevation of cardiac troponin I indicates more than myocardial ischemia. Clin Invest Med 2003; 26:133. Turer AT, Addo TA, Martin JL, et al. Myocardial ischemia induced by rapid atrial pacing causes troponin T release detectable by a highly sensitive assay: insights from a coronary sinus sampling study. J Am Coll Cardiol 2011; 57:2398. 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. When a patient presents with chest pain or symptoms suggestive of acute coronary syndrome, vital signs should be obtained, the patient should be monitored, and a focused but careful history should be obtained. and transmitted securely. Scholl, F.G., et al., Interval or permanent nonoperative management of acute type A aortic dissection. 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. Of those with a positive cTn, 42.7% of the patients did not have ACS.3. J Am Coll Cardiol. Accessed Oct. 6, 2020. Kim MN, Kim HL, Park SM, Shin MS, Yu CW, Kim MA, Hong KS, Shim WJ. K. R. DeVault, Extraesophageal symptoms of GERD, Cleveland Clinic Journal of Medicine, vol. 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. Elsevier; 2020. https://www.clinicalkey.com. 150160, 2006. 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. 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. Of these, 2,344 patients (3.3% overall, or 7.0% of those that had a cTn measured) had an elevated cTn concentration. The esophagus is a muscular tube that connects your mouth and your stomach.
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