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THE INCIDENCE OF SILENT MYOCARDIAL ISCHEMIA IN ACUTE NON-VARICEAL UPPER GASTROINTESTINAL BLEEDING (NVUGIB)
M Mawardi, J Gregor, P Walton-Mennill
Division of Gastroenterology, The University of Western Ontario, London, Ontario
BACKGROUND: Clinical observations suggest that myocardial ischemia may occur concurrently with acute NVUGIB. However, there is a paucity of literature examining the true incidence of myocardial ischemia, both overt and silent with this presentation.
METHODS: A retrospective observational study of 339 adult patients with endoscopically diagnosed acute NVUGIB presenting to London Health Sciences Centre between December 1999 and January 2005 was conducted. Patient demographics, symptomatology, serum cardiac enzymes (creatine kinase, troponin I) and electrocardiographic (ECG) changes during the initial hospital admission were reviewed. Patients were excluded if an ischemic cardiac event was diagnosed prior to the NVUGIB.
RESULTS: Four patients were excluded as the cardiac ischemic event clearly preceded the episode of NVUGIB. 124/335 patients had cardiac enzymes done within 48 hours of presentation with 36% being elevated above the upper limit of normal. 23/124 (19%) patients developed symptoms (ie. chest pain, dyspnea) compatible with cardiac ischemia. 11/23 (48%) of these patients had an ischemic event confirmed by cardiac enzymes. 101 patients had enzymes done despite a lack of cardiac symptoms. Of these 34 patients (34%) had elevation in cardiac enzymes. Nine (26%) of these patients had ECG changes diagnostic of a silent myocardial infarction. Four (44%) of these patients had no previous cardiac history.
CONCLUSION: Myocardial ischemia occurs frequently in the setting of NVUGIB and appears to be surprisingly common even in the absence of symptoms. Though less common, the incidence of concomitant myocardial infarction appears to be greater than one in ten. Even patients without a previous cardiac history or overt cardiac symptoms may be at significant risk. The long term relevance to subsequent investigation and prognosis needs further study.