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Prevalence of Silent Myocardial Ischemia and Arrhythmias in Patients With Coronary Heart Disease Undergoing Gastrointestinal Tract Endoscopic Procedures

Prevalence of Silent Myocardial Ischemia and Arrhythmias in Patients With Coronary Heart Disease... Abstract Background: Since the introduction of gastrointestinal tract endoscopic procedures, there has been concern about cardiovascular complications, especially in patients with coronary heart disease. Although, in general, these procedures are safe, previous studies have documented perturbations in blood pressure, heart rate, and oxygen saturation, as well as the occurrence of arrhythmias and nonspecific ST-segment electrocardiographic changes during such procedures. No studies, however, have specifically addressed the prevalence of silent myocardial ischemia and arrhythmias in patients with well-established coronary heart disease. Methods: During a 15-month period, 25 hospitalized patients with well-defined coronary heart disease underwent continuous ambulatory electrocardiographic recording during endoscopic procedures requiring intravenous sedation, as well as during a prolonged baseline period. All patients were considered clinically stable, although 92% were categorized as being at intermediate or high coronary risk by standard risk stratification criteria. Eleven patients (44%) had had previous myocardial infarction, and 68% reported a history of angina. Results: Although 24% of patients had one or more episodes of electrocardiographic ischemia during the recording periods, no patient had evidence of ischemia exclusively during the endoscopic procedure. Arrhythmias were no more frequent during the endoscopic procedures than during a corresponding baseline period. Symptomatic angina or serious arrhythmias did not occur during the procedures. Conclusions: Our data suggest that endoscopic procedures in patients with stable but severe coronary heart disease, when performed with standard medications, monitoring, and techniques, rarely result in silent or symptomatic myocardial ischemia or serious arrhythmias. In addition, although asymptomatic minor arrhythmias are common during endoscopic procedures, their occurrence appears less frequent than during daily hospital life.(Arch Intern Med. 1993;153:2325-2330) References 1. Kinoshita Y, Ishido S, Nishiyama K, et al. Arterial oxygen saturation, blood pressure, and pulse rate during upper gastrointestinal endoscopy: influence of sedation and age . J Clin Gastroenterol. 1991;13:656-660.Crossref 2. Fennerty MB, Earnest DL, Hudson PB, Sampliner RE. Physiologic changes during colonoscopy . Gastrointest Endosc. 1990;36:22-25.Crossref 3. Woods SDS, Chung SCS, Leung JWC, Chan ACW, Li AKC. Hypoxia and tachycardia during endoscopic retrograde cholangiopancreatography: detection by pulse oximetry . Gastrointest Endosc. 1989;35:523-525.Crossref 4. Levy N, Abinader E. Continuous electrocardiographic monitoring with Holter electrocardiocorder throughout all stages of gastroscopy . Dig Dis Sci. 1977; 22:1091-1096.Crossref 5. Segawa K, Nakazawa S, Yamao K, et al. Cardiac response to upper gastrointestinal endoscopy . Am J Gastroenterol. 1989;84:13-16. 6. Lieberman DA, Wuerker CK, Katon RM. Cardiopulmonary risk of esophagogastroduodenoscopy: role of endoscope diameter and systemic sedation . Gastroenterology . 1985;88:468-472. 7. Mathew PK, Ona FV, Damevski K, Wallace WA. Arrhythmias during upper gastrointestinal endoscopy . Angiology. 1979;30:834-840.Crossref 8. Bough EW, Meyers S. Cardiovascular responses to upper gastrointestinal endoscopy . Am J Gastroenterol . 1978;69:655-661. 9. Alam M, Schuman BM, Duvernoy WFC, Madrazo AC. Continuous electrocardiographic monitoring during colonoscopy . Gastrointest Endosc . 1976;22:203-205.Crossref 10. Fujita R, Kumura F. Arrhythmias and ischemic changes of the heart induced by gastric endoscopic procedures . Am J Gastroenterol. 1975;64:44-48. 11. Pyorala K, Salmi HJ, Jussila J, Heikkila J. Electrocardiographic changes during gastroscopy . Endoscopy. 1973;5:186-193.Crossref 12. Raby KE, Goldman L, Creager MA, et al. Correlation between preoperative ischemia and major cardiac events after peripheral vascular surgery . N Engl J Med. 1989;321:1296-1300.Crossref 13. Raby KE, Barry J, Creager MA, Cook EF, Weisberg MC, Goldman L. Detection and significance of intraoperative and postoperative myocardial ischemia in peripheral vascular surgery . JAMA. 1992;268:222-227.Crossref 14. Deedwania PC, Carbajal EV. Silent myocardial ischemia . Arch Intern Med. 1991; 151:2373-2382.Crossref 15. Pepine CJ. Clinical aspects of silent myocardial ischemia in patients with angina and other forms of coronary heart disease . Am J Med. 1986;80( (suppl 4C) ):25-34.Crossref 16. Hammill SC. Evaluation of a Holter system to record ST segment changes . J Electrocardiol. 1987;20:12-15. 17. O'Rourke RA. Risk stratification after myocardial infarction: clinical overview . Circulation. 1991;84( (suppl 3) ):I177-I181.Crossref 18. Beller GA. Are you ever too old to be risk stratified? J Am Coll Cardiol. 1992; 19:1399-1401.Crossref 19. Cohn PF. Silent myocardial ischemia . Ann Intern Med. 1988;109:312-317.Crossref 20. Deanfield JE, Selwyn AP. Character and causes of transient myocardial ischemia during daily life: implications for treatment of patients with coronary disease . Am J Med. 1986;80( (suppl 4C) ):18-24.Crossref 21. Gottlieb SO, Weisfeldt ML, Ouyang P, Mellits ED, Gerstenblith G. Silent ischemia as a marker for early unfavorable outcomes in patients with unstable angina . N Engl J Med. 1986;314:1214-1219.Crossref 22. Deanfield JE, Shea M, Ribiero P, et al. Transient ST-segment depression as a marker of myocardial ischemia during daily life . Am J Cardiol. 1984;54:1195-1200.Crossref 23. Katz D, Selesnick S. Cardiac arrest during gastroscopy . Gastroenterology . 1957; 33:650-653. 24. Davison ET, Levine M, Meyerowitz R. Ventricular fibrillation during colonoscopy: case report and review of the literature . Am J Gastroenterol. 1985;80: 690-693. 25. Pristautz H, Biffl H, Leitner W, Parsche P, Schmid P. Influence of antiarrhythmic premedication on the development of premature ventricular contractions during fiberoptic gastroduodenoscopy . Endoscopy. 1981;13:57-59.Crossref 26. Muller JE, Stone PH, Turi ZG. Circadian variation in the frequency of onset of acute myocardial infarction . N Engl J Med. 1985;313:1315-1322.Crossref 27. Jaffe JH, Martin WR. Opioid analgesics and antagonists . In: Gilman AG, Goodman LS, Gilman A, eds. Goodman and Gilman's The Pharmacologic Basis of Therapeutics . New York, NY: Macmillan Publishing Co Inc; 1990:494-534. 28. Reves JG, Fragen RJ, Vinik RH, Greenblatt DJ. Midazolam: pharmacology and uses . Anesthesiology. 1985;62:310-324.Crossref 29. Weiner N. Atropine, scopolamine, and related antimuscarinic drugs . In: Gilman AG, Goodman LS, Gilman A, eds. Goodman and Gilman's The Pharmacologic Basis of Therapeutics . New York, NY: Macmillan Publishing Co Inc; 1990:120-137. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Prevalence of Silent Myocardial Ischemia and Arrhythmias in Patients With Coronary Heart Disease Undergoing Gastrointestinal Tract Endoscopic Procedures

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References (33)

Publisher
American Medical Association
Copyright
Copyright © 1993 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1993.00410200039005
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Abstract

Abstract Background: Since the introduction of gastrointestinal tract endoscopic procedures, there has been concern about cardiovascular complications, especially in patients with coronary heart disease. Although, in general, these procedures are safe, previous studies have documented perturbations in blood pressure, heart rate, and oxygen saturation, as well as the occurrence of arrhythmias and nonspecific ST-segment electrocardiographic changes during such procedures. No studies, however, have specifically addressed the prevalence of silent myocardial ischemia and arrhythmias in patients with well-established coronary heart disease. Methods: During a 15-month period, 25 hospitalized patients with well-defined coronary heart disease underwent continuous ambulatory electrocardiographic recording during endoscopic procedures requiring intravenous sedation, as well as during a prolonged baseline period. All patients were considered clinically stable, although 92% were categorized as being at intermediate or high coronary risk by standard risk stratification criteria. Eleven patients (44%) had had previous myocardial infarction, and 68% reported a history of angina. Results: Although 24% of patients had one or more episodes of electrocardiographic ischemia during the recording periods, no patient had evidence of ischemia exclusively during the endoscopic procedure. Arrhythmias were no more frequent during the endoscopic procedures than during a corresponding baseline period. Symptomatic angina or serious arrhythmias did not occur during the procedures. Conclusions: Our data suggest that endoscopic procedures in patients with stable but severe coronary heart disease, when performed with standard medications, monitoring, and techniques, rarely result in silent or symptomatic myocardial ischemia or serious arrhythmias. In addition, although asymptomatic minor arrhythmias are common during endoscopic procedures, their occurrence appears less frequent than during daily hospital life.(Arch Intern Med. 1993;153:2325-2330) References 1. Kinoshita Y, Ishido S, Nishiyama K, et al. Arterial oxygen saturation, blood pressure, and pulse rate during upper gastrointestinal endoscopy: influence of sedation and age . J Clin Gastroenterol. 1991;13:656-660.Crossref 2. Fennerty MB, Earnest DL, Hudson PB, Sampliner RE. Physiologic changes during colonoscopy . Gastrointest Endosc. 1990;36:22-25.Crossref 3. Woods SDS, Chung SCS, Leung JWC, Chan ACW, Li AKC. Hypoxia and tachycardia during endoscopic retrograde cholangiopancreatography: detection by pulse oximetry . Gastrointest Endosc. 1989;35:523-525.Crossref 4. Levy N, Abinader E. Continuous electrocardiographic monitoring with Holter electrocardiocorder throughout all stages of gastroscopy . Dig Dis Sci. 1977; 22:1091-1096.Crossref 5. Segawa K, Nakazawa S, Yamao K, et al. Cardiac response to upper gastrointestinal endoscopy . Am J Gastroenterol. 1989;84:13-16. 6. Lieberman DA, Wuerker CK, Katon RM. Cardiopulmonary risk of esophagogastroduodenoscopy: role of endoscope diameter and systemic sedation . Gastroenterology . 1985;88:468-472. 7. Mathew PK, Ona FV, Damevski K, Wallace WA. Arrhythmias during upper gastrointestinal endoscopy . Angiology. 1979;30:834-840.Crossref 8. Bough EW, Meyers S. Cardiovascular responses to upper gastrointestinal endoscopy . Am J Gastroenterol . 1978;69:655-661. 9. Alam M, Schuman BM, Duvernoy WFC, Madrazo AC. Continuous electrocardiographic monitoring during colonoscopy . Gastrointest Endosc . 1976;22:203-205.Crossref 10. Fujita R, Kumura F. Arrhythmias and ischemic changes of the heart induced by gastric endoscopic procedures . Am J Gastroenterol. 1975;64:44-48. 11. Pyorala K, Salmi HJ, Jussila J, Heikkila J. Electrocardiographic changes during gastroscopy . Endoscopy. 1973;5:186-193.Crossref 12. Raby KE, Goldman L, Creager MA, et al. Correlation between preoperative ischemia and major cardiac events after peripheral vascular surgery . N Engl J Med. 1989;321:1296-1300.Crossref 13. Raby KE, Barry J, Creager MA, Cook EF, Weisberg MC, Goldman L. Detection and significance of intraoperative and postoperative myocardial ischemia in peripheral vascular surgery . JAMA. 1992;268:222-227.Crossref 14. Deedwania PC, Carbajal EV. Silent myocardial ischemia . Arch Intern Med. 1991; 151:2373-2382.Crossref 15. Pepine CJ. Clinical aspects of silent myocardial ischemia in patients with angina and other forms of coronary heart disease . Am J Med. 1986;80( (suppl 4C) ):25-34.Crossref 16. Hammill SC. Evaluation of a Holter system to record ST segment changes . J Electrocardiol. 1987;20:12-15. 17. O'Rourke RA. Risk stratification after myocardial infarction: clinical overview . Circulation. 1991;84( (suppl 3) ):I177-I181.Crossref 18. Beller GA. Are you ever too old to be risk stratified? J Am Coll Cardiol. 1992; 19:1399-1401.Crossref 19. Cohn PF. Silent myocardial ischemia . Ann Intern Med. 1988;109:312-317.Crossref 20. Deanfield JE, Selwyn AP. Character and causes of transient myocardial ischemia during daily life: implications for treatment of patients with coronary disease . Am J Med. 1986;80( (suppl 4C) ):18-24.Crossref 21. Gottlieb SO, Weisfeldt ML, Ouyang P, Mellits ED, Gerstenblith G. Silent ischemia as a marker for early unfavorable outcomes in patients with unstable angina . N Engl J Med. 1986;314:1214-1219.Crossref 22. Deanfield JE, Shea M, Ribiero P, et al. Transient ST-segment depression as a marker of myocardial ischemia during daily life . Am J Cardiol. 1984;54:1195-1200.Crossref 23. Katz D, Selesnick S. Cardiac arrest during gastroscopy . Gastroenterology . 1957; 33:650-653. 24. Davison ET, Levine M, Meyerowitz R. Ventricular fibrillation during colonoscopy: case report and review of the literature . Am J Gastroenterol. 1985;80: 690-693. 25. Pristautz H, Biffl H, Leitner W, Parsche P, Schmid P. Influence of antiarrhythmic premedication on the development of premature ventricular contractions during fiberoptic gastroduodenoscopy . Endoscopy. 1981;13:57-59.Crossref 26. Muller JE, Stone PH, Turi ZG. Circadian variation in the frequency of onset of acute myocardial infarction . N Engl J Med. 1985;313:1315-1322.Crossref 27. Jaffe JH, Martin WR. Opioid analgesics and antagonists . In: Gilman AG, Goodman LS, Gilman A, eds. Goodman and Gilman's The Pharmacologic Basis of Therapeutics . New York, NY: Macmillan Publishing Co Inc; 1990:494-534. 28. Reves JG, Fragen RJ, Vinik RH, Greenblatt DJ. Midazolam: pharmacology and uses . Anesthesiology. 1985;62:310-324.Crossref 29. Weiner N. Atropine, scopolamine, and related antimuscarinic drugs . In: Gilman AG, Goodman LS, Gilman A, eds. Goodman and Gilman's The Pharmacologic Basis of Therapeutics . New York, NY: Macmillan Publishing Co Inc; 1990:120-137.

Journal

Archives of Internal Medicine – American Medical Association

Published: Oct 25, 1993

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