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Serum Cardiac Markers Of Patients Before And After Upper Gastrointestinal System Endoscopy
Üst Gastrointestinal Sistem Endoskopisi Önce ve Sonrasında Serum Kardiyak Marker Değerlendirmeleri
Onder Sezer, Binnur Tagtekin Sezer

 

How to cite / Atıf için: Sezer O, Tagtekin Sezer B. Serum Cardiac Markers Of Patients Before And After Upper Gastrointestinal System Endoscopy. Euras J Fam Med 2016;5(2):62-6

 

Original Research / Orijinal Araştırma


ABSTRACT

Aim: Endoscopy is widely used to diagnose and treat gastrointestinal system diseases. It is a safe method but cardiopulmonary complications are the most common reasons about mortality. In this study we tried to determine early myocardial ischemia or infarction of upper gastrointestinal endoscopy performed patients by measured cardiac enzyme levels.

Methods: Patients who had chest pain before endoscopy and didn’t have chronical disease were chosen for our study. In our restrospective cross sectional study, Troponin-I and CK-MB levels of patients before and 4 hours after endoscopy were taken from their files.

Results: Twenty-one patients chosen for our study. Seven (33.3%) of them had elevated troponin-I levels; but they were within the range of limiting values. If we include all patients, troponin rise after endoscopy was statistically significant (p=0.01), but not pathologic.

Conclusion: In our study, we tried to determine the risk of myocard ischemia or infarct on patients suffering from chest pain before endoscopy. There was no evidence of troponin-I and CK-MB values that lead to myocardial damage. No myocardial infarction detected. Our results were similar to other studies. We want to continue our study prospectively; by increasing number of patients,to pronounce certain results.

Keywords: endoscopy, troponin, creatine kinase, myocard, cardiac diseases

ÖZET

Amaç: Endoskopi, gastrointestinal sistem hastalıklarının tanı ve tedavisinde yaygın olarak kullanılan bir yöntemdir. Güvenli olmasının yanında, en sık .lüm nedeni kardiyopulmoner sistemle ilgili komplikasyonlardır. Bu çalışmada üst gastrointestinal sistem endoskopisi yapılan hastalarda işlem öncesi ve sonrası erken dönemde miyokardiyal iskemi, miyokardiyal hasar ve miyokard infarktüsü varlığını kardiyak enzim düzeylerini değerlendirerek saptamayı amaçladık.

Yöntemler: Çalışmamız endoskopi işlemi yapılmadan önce göğüs ağrısı tarifleyen, bilinen kronik hastalığı olmayan hastalar ile yapıldı. Retrospektif kesitsel çalışmamızda hastaların işlem öncesi ve işlemden sonraki 4. saatte bakılan kardiyak troponin ve kreatin kinaz-MB(CK-MB) değerleri karşılaştırıldı.

Bulgular: Çalışmaya 21 hasta alındı. Yedi (%33,3) tanesinin bakılan troponin değerlerinde yükselme saptandı ancak bu değerler normal sınırlardaydı, ve yükseliş anlamlı değildi. Tüm hastalar dahil edildiğinde hastaların endoskopi öncesi ve sonrasında bakılan troponin değerlerindeki değişim patolojik olmasa da anlamlıydı.

Sonuç: Çalışmamızda daha önceden göğüs ağrısı tarifleyen ve endoskopi yapılan hastalarda miyokardiyal iskemi veya infarkt riskini saptamayı amaçladık. Troponin-I ve CK-MB değerlerinde miyokardiyal hasara veya infarkta yönelik kanıt saptamadık. Kesin sonuçlara ulaşabilmek için çalışmamıza hasta sayısını arttırarak, prospektif olarak devam etmek istiyoruz.

Anahtar kelimeler: endoskopi, troponin, kreatin kinaz, miyokard, kalp hastalıkları


Introduction

Upper gastrointestinal endoscopy is widely used to diagnose and treat gastrointestinal system diseases (1). It is a safe method but sometimes cardiopulmonary complications occur. Sixty percent of deaths due to complications are cardiopulmonary. Changes of blood pressure and oxygen saturation are responsible for this during endoscopy (2). To identify myocardial infarction, we can use cardiac troponin levels (3). During cardiac or non-cardiac procedures, measuring troponin I to show myocardial infarct is a sensitive and spesific method. Because of infarction, troponin I level rises in 4 to 6 hours and stays higher through 3 to 10 days (4). Table 1 shows other reasons that raise troponin I levels. 

 

Table 1. Troponin-I raising reasons other than myocard infarction

 

Another test to specify myocardial infarction is creatine kinase (CK-MB) (5). Other than myocardial muscle, it is also found in skeletal muscle, tongue, diaphragm, small intestine, uterus and prostate gland (6). CK-MB level rises in 4 to 6 hours and comes to normal in 2-3 days in certain pathological situations. It can be used to diagnose early or late myocardial infarction (5). 

In this study we tried to determine early myocardial ischemia or infarction of upper gastrointestinal endoscopy performed patients by measured cardiac enzyme levels.

Methods

We chose 21 patients who had myocardial ischemia and didn’t have known chronical disease. In our restrospective cross sectional study, Troponin I and CK-MB levels of patients before and 4 hours after endoscopy were achieved from their files. Limiting values of troponin-I was 0 to 0.06 ng/mL; and limiting values of CK-MB was 0 to 5 ng/mL.  Collected data analyzed through SPSS v19.0 by using chi-square and percentage frequency.

Results

Twenty-one patients had chosen for our study. Fourteen (66.7%) were male and 7 (33.3%) were female. Age distribution was 24 to 87 and mean age of patients was 52.86 (±17,077). Seven patients were over 65 years old.

Seven (33.3%) patients troponin levels had elevated (table 2); but they were between limiting values and wasn’t statistically significant (p=0.05). Four of these patients were over 65 years old. If we include all patients, troponin rise after endoscopy was statistically significant (p=0.01). For CK-MB, the raise was statistically insignificant (p=0.047). 50% of men’s and 14.3% of women’s CK-MB levels had elevated (Table 3). When we looked at troponin-I levels, 35,7% of men’s and 28,5% of women’s had elevated. Four of our patients had gone through both troponin-I and CK-MB rising. 

 

Table 2: Patients who had elevated troponin levels

 

If we include all patients, troponin rise after endoscopy was statistically significant (p=0.01)  (Image 1); but for CK-MB, it is statistically insignificant (p=0.047). 50% of men’s and 14.3% of women’s CK-MB levels had elevated (Table 3). 

 

Table 3 : Patients who had elevated CK-MB levels

Image 1: Troponin-I levels of all patients before and after endoscopy

 

Discussion

Esophagogastroduodenoscopy is performing widely to diagnose or treat some diseases. Treatments like polypectomy without opening abdomen, taking foreign bodies, cholangiopancreatography, treating hemorrhagic ulcers are performing by endoscopes (7).

Although it is a widely used and safe procedure, rarely death takes place. Sixty percent of deaths take place due to cardiopulmonary complications. Fifty percent of complications after endoscopy are cardiopulmonary. Arythmia, ST-T changes, blood pressure and oxygen saturation changes are examples of these complications (2). After long time ischemia, myocardial infarct takes place (8).

Situations leading to acute coronary syndrome during endoscopy can be gathered under 4 headlines:

  1. Mechanical stress due to endoscopy: Stimulation of inferior esophagus and gastric distension can lead to reflex activation. Hypertension, arrythmia and angina can take place because of stimulation of gastrovascular and viscerocardiac reflexes.
  2. Autonomic nervous system activation: During esophagogastroduodenoscopy (EGD), sympathetic system activates. After that, cardiac arrythmia and myocardial ischemia can easily take shape.
  3. Sedation and analgesia: Especially on hypovolemic, old and comorbid patients, sedation and analgesia can lead to complications.
  4. Anxiety and neuroendocrine response to stress: Before and after procedure, serum catecholamine, cortisol and glucose levels elevate due to stress hormones (9).

In the study of Özdoğan M. et al (2), 50% of patients had sinus tachycardia after endoscopy; and 90% of patients had blood pressure elevation and arrythmia. These changes were not related to age and sex. 

In the study of Güvel S. et al (6), they searched for myocardial ischemia or infarction before and after transurethral prostatectomy. In the end, 12,5% of patients had troponin-I raise leading to myocardial ischemia; none of them had myocardial infarct. Also 45% of patients had CK-MB elevation. In our study, 50% of men’s and 14.3% of women’s CK-MB levels elevated. When we looked at troponin levels, 35,7% of men’s and 28,5% of women’s were elevated after endoscopy.   

In the study of Yazawa K. et al (10), after inserting the endoscope, heart rate rises up in patients with known cardiac disease. Number of patients who had ventricular and supraventricular extrasystoles during the procedure was higher and it is calculated as statistically significant.

In the study of Gangi S. et al (11), being male and using propofol were risk factors for cardiac complications. Also in our study, CK-MB and troponin-I elevation was higher in male patients. 

In 164 patients of Thompson AM. et al (12) study, cardiopulmonary incidents are more common in esophagial dilatation endoscopy than diagnostic endoscopy.

In the retrospective study of Spier BJ. et al (13), there was no statistically significant risk of endoscopy in post-MI patients.

In the study of Martin DF. et al (14), there wasn’t any troponin-T changes for myocardial damage after procedure.

In the prospective study of Iser DM. et al (15), being over 65 years old, and a recent history of cardiac disease were associated with troponin release. In our study, 7 (33.3%) patients had elevated troponin-I level; 4 (57,14%) of them were over 65 years old.

Conclusion 

Chest pain during endoscopy is the most common cause to stop the procedure. Also, cardiopulmonary complications are the most common cause of deaths because of endoscopy. Because of previous myocardial infarct, endoscopy can be delayed; diagnose and treatment of diseases also can be delayed. In addition to all of these, it affects psychological status of endoscopy team and reduces the percentage of achievement.

There was not any troponin-I and CK-MB values that lead to myocardial damage. No myocardial infarction detected.

Number of patients also were lower; but our results were similar to other study. By continuing prospectively and increasing number of patients, we will be able to discuss about more certain results.

In our study, we tried to determine the risk of myocardial ischemia or infarct on patients suffering from chest pain for some time before endoscopy. Previous chest pain patients and their measured cardiac enzyme levels scanned retrospectively. We couldn’t find all patients electrocardiography (EKG) and oxygen saturation findings, so they were excluded from our study.

 

References

1. Yenice N, Gençdal G, Aksoy N, Kalyon S, Akın O. The prevalence of Hepatitis B and C in patients with upper gastrointestinal endoscopy. Akademik Gastroenteroloji Dergisi 2009;8(2):82-7.

2. Özdoğan M, Gür G, Özgür O, Müderrisoğlu H, Korkmaz ME, Boyacıoğlu S. Cardiac implications of esophagogastroduodenoscopy in patients with coronary heart disease. Turk J Gastroenterol 2000;11(2):136-40.

3. Antman EM, Tanasijevic MJ, Thompson B, Schatman M, McCabe CH, Cannon CP, et al. Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med 1996;335(18):1342-9.

4. Mangano DT, Hollenberg M, Fegert G, Meyer ML, London MJ, Tubau JF, et al. Perioperative myocardial ischemia in patients undergoing noncardiac surgery-I: incidence and severity during the 4 day perioperative period. The study of perioperative ischemia (SPI) research group. J Am Coll Cardiol 1991;17(4):843-50.

5. Schreiber D, Miller SM, Brenner BE, Bessman E, Setnik G, Talavera F [Internet]. Cardiac markers [cited 2013 Sep 24]. Available from : http://emedicine.medscape.com/article/811905-overview.

6. Güvel S, Yiğit F, Kılınç F, Eğilmez T, Yaycıoğlu Ö, Özkardeş H. An early complication of transurethral prostatectomy: subclinical myocardial damage. Türk Üroloji Dergisi 2005;31(1):94-8.

7. Kırbaş G, Üstündağ G, Özden A. Üst ve alt gastrointestinal sistemin endoskopik incelemesi [Endoscopic screening of upper and lower gastrointestinal system]. Güncel Gastroenteroloji 2009;13(2):110-21. Turkish. 

8. Agewall S, Giannitsis E, Jernberg T, Katus H. Troponin elevation in coronary vs. non-coronary disease. Eur Heart J 2011;32(4):404-11.

9. Önal İK, İbiş M. Koroner arter hastalığı ve gastrointestinal kanama [Coronary artery disease and gastrointestinal hemorrhage]. Güncel Gastroenteroloji 2009;13(1):29-32. Turkish.

10. Yazawa K, Adachi W, Koide N, Watanabe H, Koike S, Hanazaki K. Changes in cardiopulmonary parameters during upper gastrointestinal endoscopy in patients with heart disease: towards safer endoscopy. Endoscopy 2000;32(4):287-93.

11. Gangi S, Saidi F, Patel K, Johnstone B, Jaeger J, Shine D. Cardiovascular complications after GI endoscopy: occurrence and risks in a large hospital system. Gastrointest Endosc 2004;60(5):679-85.

12. Thompson AM, Park KG, Kerr F, Munro A. Safety of fibreoptic endoscopy: analysis of cardiorespiratory events. Br J Surg 1992;79(10):1046-9.

13. Spier BJ, Said A, Moncher K, Pfau PR. Safety of endoscopy after myocardial infarction based on cardiovascular risk categories: a retrospective analysis of 135 patients at a tertiary referral medical center. J Clin Gastroenterol 2007;41(5):462-7.

14. Martin DF, Laasch HU, Kelly AM, Hammonds R, Wilbraham L, Sastry S, et al. Troponin T after endoscopic retrograde cholangiopancreatography: no evidence of harm. Endoscopy 2006;38(8):793-6.

15. Iser DM, Thompson AJ, Sia KK, Yeomans ND, Chen RY. Prospective study of cardiac troponin I release in patients with upper gastrointestinal bleeding. J Gastroenterol Hepatol 2008;23(6):938-42.

 


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