Esophageal spasms are sometimes associated with conditions such as heartburn or gastroesophageal reflux disease (GERD). Subendocardial ischemia classically results in ST-segment depression and T-wave inversion.14 Approximately 25 percent of patients with ST-segment depression and elevated creatine kinaseMB isoenzyme (CK-MB) levels eventually develop STEMI, and 75 percent have NSTEMI. Diffuse esophageal spasm (corkscrew esophagus). 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. The .gov means its official. Occasionally, reciprocal ST-segment depression occurs in leads that are electrically opposite to the area of injury. 15, no. WebGiven extensive prior cardiac history, anginal equivalent symptoms, ischemic ECG changes, and elevated troponin I levels, non-ST elevation myocardial infarction (d) Left internal mammary artery graft to distal left anterior descending widely patent. Troponin: What Is it, Tests, and More - Healthline 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. Acute Coronary Syndrome: An Unusual Consequence of GERD eCollection 2022. Epub 2017 Aug 1. The presentation is variable and can mimic other conditions such as aortic dissection, pulmonary embolism, and myocardial infarction (MI). The troponin I levels peaked at 2.6 (normal <0.04ng/mL) and creatinine kinase levels were within normal limits. and transmitted securely. High troponin levels can be a sign of a heart attack or other heart damage. 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. spasm Renal failure (acute kidney injury or chronic kidney disease): Multiple etiologies, but at least partially related to reduced renal clearance of troponin. Only about 2 percent of patients with cocaine-associated chest pain have acute coronary syndrome.4. The serum CK level rises within three to eight hours after myocardial injury, peaks by 12 to 24 hours, and returns to baseline within three to four days.16 A serum CK level may be used as a screening test to determine the need for more specific testing. Before one concludes that an abnormal cTnI level is a false-positive result, the possibility of coronary vasospasm should be considered. Four patients staffed by one full-time nurse; 4. However, the CK-MB subform assay is not yet widely available. 13, no. FOIA 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. Esophageal Rupture Presenting with ST Some kinds of troponin are only found in the heart muscle. Cardiac Troponin Elevations in Patients Without Acute Feldman, A.M. and D. McNamara, Myocarditis. Apple, F.S., et al., Predictive value of cardiac troponin I and T for subsequent death in end-stage renal disease. Bedside troponin assays are being developed. The physical examination in patients with acute coronary syndrome frequently is normal. Elevated cTn in asymptomatic CKD is common, the frequency which is dependent on the assay (cTnT > cTnI) and cut-off value used. Bookshelf Esophageal spasms are sometimes associated with conditions such as heartburn or gastroesophageal reflux disease (GERD). 104, no. elevated troponin Difficulty swallowing solids and liquids, sometimes related to swallowing specific substances. 2001 Oct;18(7):573-9. doi: 10.1046/j.1540-8175.2001.00573.x. In general, renal failure in the absence of symptoms/signs of ischemia is best classified as a non-MI troponin elevation. Goldman L, et al., eds. He denied any associated palpitations, dizziness, nausea, vomiting, or epigastric abdominal pain. 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. Atypical symptoms do not necessarily rule out acute coronary syndrome. Januzzi, and R.H. Christenson, Increases of cardiac troponin in conditions other than acute coronary syndrome and heart failure. 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. 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 2022 Jul 8;17(7):e0271189. Unable to load your collection due to an error, Unable to load your delegates due to an error. 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. Copyright 2015 Chui Man Carmen Hui et al. It is important to remember that an MI specifically refers to myocardial injury due to acute myocardial ischemia to the myocardium. A 12-lead ECG should be obtained within 10 minutes of presentation.7. Ominous physical findings include a new mitral regurgitation murmur, hypotension, pulmonary rales, a new third heart sound (S3 gallop), and new jugular venous distention. 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. Kim MN, Kim HL, Park SM, Shin MS, Yu CW, Kim MA, Hong KS, Shim WJ. Coronary vasospasm can be elicited by stimulation of alpha-adrenergic, histaminic, Furthermore, Swiatowski et al. (c) Sequential vein graft to right posterolateral and posterior descending artery with 40% proximal disease. 9, pp. 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. Aviles, R.J., et al., Troponin T Levels in Patients with Acute Coronary Syndromes, with or without Renal Dysfunction. It's not clear what causes esophageal spasms. Y. Liu, S. He, Y. Chen et al., Acid reflux in patients with coronary artery disease and refractory chest pain, Internal Medicine, vol. CK-MB2 is found in myocardial tissue, and CK-MB1 is found in plasma. 11, pp. Some people may mistake it for heart pain, also called angina. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). 2010 December 15, 2009 [cited 2010 August 3]; Available from: Kelley, W.E., J.L. This is of course problematic, as the incidence and prevalence of coronary artery disease and ACS is high in this population. The pain is often intense, and you might mistake it for heart pain, also known as angina. 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). Early markers of acute ischemia include myoglobin and creatine kinaseMB subforms (or isoforms), when available. 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. A. Ambrose, Chest pain from gastroesophageal reflux disease in patients with coronary artery disease, Cardiology in Review, vol. J. P. Liuzzo and J. 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. Esophageal spasms can feel like sudden, severe chest pain that lasts from a few minutes to hours. With older conventional assays, cTnI or T is typically measurable as early as 3-4 hours following myocardial injury. There are no known risk factors for esophageal spasms. 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. Thompson PD, Klocke FJ, Levine BD, Van Camp SP. Pain from esophageal spasm is one distinct possibility for precipitating ischemia in this patient. He also denied any nausea, vomiting, or epigastric discomfort. These include: food and drink, such as red wine or spicy food. 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. 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. 167173, 2005. He had no further ischemic episodes after increasing the dose of antireflux medication over a 6-month follow-up. 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. 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. Merck Manual Professional Version. It is also possible that myocardial ischemia in our patient was due to esophagocardiac reflex, which describes myocardial ischemia associated with chemical esophageal stimulation. 16211628, 1996. All too often, esophageal spasm is diagnosed on the basis of minor In the setting of irreversible myocardial cell injury, the contents of the cTn complex are released into circulation. All rights reserved. The feeling that an object is stuck in your throat. Cureus. Epub 2015 Oct 27. UpToDate Elevated Of 218 episodes of ST-segment depression, 45 (20.6%) correlated with pathologic reflux. 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 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. Cardiac catheterization revealed chronic three-vessel coronary artery disease, with 2 patent grafts and 2 chronically occluded grafts. Wang CH, Cherng WJ, Meng HC, Hong MJ, Kuo LT. Echocardiography. His home medications included esomeprazole, lisinopril, metoprolol succinate, aspirin, clopidogrel, and ezetimibe. Troponin elevations tend to be mild, with more indolent (or even flat) troponin trajectories. All rights reserved. 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). Your provider might recommend a proton pump inhibitor to treat GERD. The predictive value of the ECG varies markedly, depending on the baseline risk (pretest probability) for coronary artery disease in a given patient. Gibson, C.M. 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 Feldman M, et al., eds. 11651171, 2013. Ohlmann, P., et al., Diagnostic and prognostic value of circulating D-Dimers in patients with acute aortic dissection. 20 Patients with a normal CK-MB level but 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. National Library of Medicine 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, The likelihood of silent ischemia traditionally has been thought to be greater in patients with diabetes. (b) Multiple tertiary contractions of the distal esophagus suggestive of dysmotility. 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. The magnitude of an ECG abnormality affects diagnostic accuracy. This study investigated whether coronary vasospasm could be a reason for elevated cTnI in this patient population. 4, pp. Due to this fact, the specificity of cTn for ACS in this patient population is lower compared with patients without renal disease. We hypothesized that he had myocardial ischemia due to increased oxygen demand from uncontrolled GERD symptoms. Park JY, Kang EJ, Kim MH, Yong HS, Rha SW. PLoS One. cTnI was elevated in 23 patients (25%) and was normal in 70 patients (75%). 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]. The term NSTEMI should be used only when referring to a type 1 MI not when referring to a type 2 MI.1. 1994 Oct;24(4):888-92. doi: 10.1016/0735-1097(94)90846-x. 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. (See "Diagnosis of acute myocardial infarction", During the hospitalization, the patient had another episode of nocturnal dyspnea with chest tightness. (a) Right coronary artery 100% occluded in the proximal segment. ISSN 1553-085X. Although protocols for chest pain units may vary somewhat, one protocol28 that has been shown to be safe and cost-effective in an intermediate-risk population consists of the following: 1. 150160, 2006. Various mechanisms for HF-related cTn elevation have been proposed, including subendocardial ischemia from wall tension, apoptosis, spontaneous necrosis, as well as inflammation. coronary artery spasm, History of diabetes mellitus is associated with elevated cardiac troponin I levels in patients with chest pain but no coronary heart disease. M. Swiatowski, B. Jacek, M. Klopocka et al., Suppression of gastric acid production may improve the course of angina pectoris and the results of treadmill stress test in patients with coronary artery disease, Medical Science Monitor, vol. Myoglobin should be used in conjunction with other serum markers, because its level peaks and falls rapidly in patients with ischemia. 26th Bethesda conference: recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities. Your email address will not be published. Clipboard, Search History, and several other advanced features are temporarily unavailable. 2023 American College of Cardiology Foundation. 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. WebGastrointestinal causes (eg, gastroesophageal reflux, esophageal spasm, peptic ulcer, pancreatitis, biliary disease) Musculoskeletal causes (eg, costochondritis, cervical radiculopathy) Psychiatric disorders. Acute Coronary Syndromes However, a combination of atypical symptoms improves identification of low-risk patients. Measurement of troponins I and T and/or CK-MB at admission and six to eight hours after admission; 3. Can Troponin Be Elevated Without Heart Attack Esophageal neuromuscular function and motility disorders. Based on the coronary anatomy the patient was managed conservatively with optimal medical therapy with no plan for percutaneous intervention or revascularization. Is there a clinical way to differentiate between esophageal spasm Troponin: Elevated troponin levels can indicate heart damage or even a heart attack. Serum cardiac marker determinations play a vital role in the diagnosis of acute myocardial infarction.