Roemheld syndrome (RS), or gastrocardiac syndrome, or gastric cardiac syndrome or Roemheld–Techlenburg–Ceconi syndrome or gastric-cardia, was a medical syndrome first coined by Ludwig von Roemheld (1871–1938) describing a cluster of cardiovascular symptoms stimulated by gastrointestinal changes. Although it is currently considered an obsolete medical diagnosis, recent studies have described similar clinical presentations and highlighted potential underlying mechanisms.

Symptoms and signs

Symptoms can be as follows. They are periodic, and occur only during an "episode", usually after eating. *

Sinus bradycardia Sinus bradycardia is a sinus rhythm with a reduced rate of electrical discharge from the sinoatrial node, resulting in a bradycardia, a heart rate that is lower than the normal range (60–100 beats per minute for adult humans). Signs and sympt ...

* Difficulty inhaling *

Angina pectoris Angina, also known as angina pectoris, is chest pain or pressure, usually caused by insufficient blood flow to the heart muscle (myocardium). It is most commonly a symptom of coronary artery disease. Angina is typically the result of part ...

* Left ventricular discomfort * Premature heart beats (

PVC Polyvinyl chloride (alternatively: poly(vinyl chloride), colloquial: vinyl or polyvinyl; abbreviated: PVC) is the world's third-most widely produced synthetic polymer of plastic (after polyethylene and polypropylene). About 40 million tons o ...

PAC Pac or PAC may refer to: Aviation * IATA code PAC Albrook "Marcos A. Gelabert" International Airport in Panama City, Panama * Pacific Aerospace Corporation, New Zealand, manufacturer of aircraft: ** PAC 750XL ** PAC Cresco ** PAC CT/4 ** PA ...

) *

Tachycardia Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal ...

Fatigue Fatigue is a state of tiredness (which is not sleepiness), exhaustion or loss of energy. It is a signs and symptoms, symptom of any of various diseases; it is not a disease in itself. Fatigue (in the medical sense) is sometimes associated wit ...

Anxiety Anxiety is an emotion characterised by an unpleasant state of inner wikt:turmoil, turmoil and includes feelings of dread over Anticipation, anticipated events. Anxiety is different from fear in that fear is defined as the emotional response ...

* Uncomfortable breathing * Poor

perfusion Perfusion is the passage of fluid through the circulatory system or lymphatic system to an organ (anatomy), organ or a tissue (biology), tissue, usually referring to the delivery of blood to a capillary bed in tissue. Perfusion may also refer t ...

* Muscle pain (crampiness) * Burst or sustained

vertigo Vertigo is a condition in which a person has the sensation that they are moving, or that objects around them are moving, when they are not. Often it feels like a spinning or swaying movement. It may be associated with nausea, vomiting, perspira ...

or dizziness *

Sleep disturbance A sleep disorder, or somnipathy, is a medical disorder affecting an individual's sleep patterns, sometimes impacting physical, mental, social, and emotional functioning. Polysomnography and actigraphy are tests commonly ordered for diagnosing s ...

(particularly when sleeping within a few hours of eating, or lying on the left side) *

Hot flashes Hot flushes are a form of flushing, often caused by the changing hormone levels that are characteristic of menopause. They are typically experienced as a feeling of intense heat with sweating and rapid heartbeat, and may typically last from tw ...

Mechanical

Mechanically induced Roemheld syndrome is characterized by

pressure Pressure (symbol: ''p'' or ''P'') is the force applied perpendicular to the surface of an object per unit area over which that force is distributed. Gauge pressure (also spelled ''gage'' pressure)The preferred spelling varies by country and eve ...

in the epigastric and left

hypochondriac Hypochondriasis or hypochondria is a condition in which a person is excessively and unduly worried about having a serious illness. Hypochondria is an old concept whose meaning has repeatedly changed over its lifespan. It has been claimed that th ...

region. Often the pressure is in the

fundus ''Fundus'' (Latin for "bottom") is an anatomical term referring to that part of a concavity in any organ, which is at the far end from its opening. It may refer to: Anatomy * Fundus (brain), the deepest part of any sulcus of the cerebral cortex * F ...

of the stomach, the

esophagus The esophagus (American English), oesophagus (British English), or œsophagus (Œ, archaic spelling) (American and British English spelling differences#ae and oe, see spelling difference) all ; : ((o)e)(œ)sophagi or ((o)e)(œ)sophaguses), c ...

or distention of the bowel. It is believed this leads to elevation of the

diaphragm Diaphragm may refer to: Anatomy * Thoracic diaphragm, a thin sheet of muscle between the thorax and the abdomen * Pelvic diaphragm or pelvic floor, a pelvic structure * Urogenital diaphragm or triangular ligament, a pelvic structure Other * Diap ...

, and secondary displacement of the heart. This reduces the ability of the heart to fill and increases the

contractility of the heart Myocardial contractility represents the innate ability of the heart muscle (cardiac muscle or myocardium) to contract. It is the maximum attainable value for the force of contraction of a given heart. The ability to produce changes in force during ...

to maintain homeostasis.

Neurological

The cranium dysfunction mechanical changes in the gut can compress the

vagus nerve The vagus nerve, also known as the tenth cranial nerve (CN X), plays a crucial role in the autonomic nervous system, which is responsible for regulating involuntary functions within the human body. This nerve carries both sensory and motor fibe ...

at any number of locations along the vagus, slowing the heart. As the heart slows, autonomic reflexes are triggered to increase blood pressure and heart rate. This is complemented by gastro-coronary reflexes whereby the coronary arteries constrict with "functional

cardiovascular In vertebrates, the circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the body. It includes the cardiovascular system, or vascular system, that consists of the heart a ...

symptoms" similar to chest-pain on the left side and radiation to the left shoulder, dyspnea, sweating, up to angina pectoris-like attacks with extrasystoles, drop of blood pressure, and tachycardia (high heart rate) or sinus bradycardia (heart rate below 60 bpm). Typically, there are no changes/abnormalities related in the

EKG Electrocardiography is the process of producing an electrocardiogram (ECG or EKG), a recording of the heart's electrical activity through repeated cardiac cycles. It is an electrogram of the heart which is a graph of voltage versus time of t ...

detected. This can actually trigger a heart attack in people with cardiac structural abnormalities i.e.

coronary bridge A myocardial bridge (MB) is a common congenital heart anomaly in which one of the coronary arteries tunnels through the heart muscle (myocardium) itself. In most people, the coronary arteries rest on top of the heart muscle and feed blood dow ...

, missing coronary, and

atherosclerosis Atherosclerosis is a pattern of the disease arteriosclerosis, characterized by development of abnormalities called lesions in walls of arteries. This is a chronic inflammatory disease involving many different cell types and is driven by eleva ...

. If the heart rate drops too low for too long,

catecholamines A catecholamine (; abbreviated CA), most typically a 3,4-dihydroxyphenethylamine, is a monoamine neurotransmitter, an organic compound that has a catechol (benzene with two hydroxyl side groups next to each other) and a side-chain amine. ...

are released to counteract any lowering of blood pressure. Catecholamines bind to alpha receptors and

beta receptors The adrenergic receptors or adrenoceptors are a class of G protein-coupled receptors that are targets of many catecholamines like norepinephrine (noradrenaline) and epinephrine (adrenaline) produced by the body, but also many medications like bet ...

, decreasing

vasodilation Vasodilation, also known as vasorelaxation, is the widening of blood vessels. It results from relaxation of smooth muscle cells within the vessel walls, in particular in the large veins, large arteries, and smaller arterioles. Blood vessel wa ...

and increasing

. Sustaining this state causes heart fatigue which can lead to a decline in systolic and

diastolic function In clinical cardiology the term "diastolic function" is most commonly referred as how the heart fills. Parallel to "diastolic function", the term " systolic function" is usually referenced in terms of the left ventricular ejection fraction (LVEF), w ...

, resulting in fatigue and chest pain.

Causes

Gastroesophageal reflux disease Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is a chronic upper gastrointestinal disease in which stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/or ...

(GERD) * Excessive gas in the

transverse colon In human anatomy, the transverse colon is the longest and most movable part of the Large intestine#Structure, colon. Anatomical position It crosses the abdomen from the ascending colon at the right colic flexure (hepatic flexure) with a downward ...

caused by: **

Lactose intolerance Lactose intolerance is caused by a lessened ability or a complete inability to digest lactose, a sugar found in dairy products. Humans vary in the amount of lactose they can tolerate before symptoms develop. Symptoms may include abdominal pain ...

* Abnormal

gallbladder In vertebrates, the gallbladder, also known as the cholecyst, is a small hollow Organ (anatomy), organ where bile is stored and concentrated before it is released into the small intestine. In humans, the pear-shaped gallbladder lies beneath t ...

function and/or blood flow *

Gall stones A gallstone is a stone formed within the gallbladder from precipitated bile components. The term cholelithiasis may refer to the presence of gallstones or to any disease caused by gallstones, and choledocholithiasis refers to the presence of mi ...

* Sphincter of Oddi dysfunction *

Hiatal hernia A hiatal hernia or hiatus hernia is a type of hernia in which abdominal organs (typically the stomach) slip through the diaphragm into the middle compartment of the chest. This may result in gastroesophageal reflux disease (GERD) or laryng ...

* Cardiac bridge (Coronary occluding reflexes triggered by coronary reflexes) *

Enteric disease Gastrointestinal diseases (abbrev. GI diseases or GI illnesses) refer to diseases involving the gastrointestinal tract, namely the esophagus, stomach, small intestine, large intestine and rectum; and the accessory organs of digestion, the liver, ...

* Aneructonia, the inability to belch (continuous or intermittent), also referred to as retrograde cricopharyngeus dysfunction (R-CPD) *

Bowel obstruction Bowel obstruction, also known as intestinal obstruction, is a mechanical or Ileus, functional obstruction of the Gastrointestinal tract#Lower gastrointestinal tract, intestines which prevents the normal movement of the products of digestion. Ei ...

(Less common, this usually leads to intense pain in short time) * Acute pancreatic necrosis *

Eosinophilia Eosinophilia is a condition in which the eosinophil count in the peripheral blood exceeds . Hypereosinophilia is an elevation in an individual's circulating blood eosinophil count above 1.5 billion/ L (1,500/ μL). The hypereosinophilic syndrome ...

Diagnosis

There is significant scope of misdiagnosis of Roemheld syndrome. Diagnosis of Roemheld syndrome usually begins with a cardiac workup, as the gastric symptoms may go unnoticed, and the cardiac symptoms are frightening and can be quite severe. After an

Holter monitor In medicine, a Holter monitor (often simply Holter) is a type of ambulatory electrocardiography device, a portable device for cardiac monitoring (the monitoring of the electrical activity of the cardiovascular system) for at least 24 hours. ...

tilt table test A tilt table test (TTT), occasionally called upright tilt testing (UTT), is a medical procedure often used to diagnose dysautonomia or syncope. Patients with symptoms of dizziness or lightheadedness, with or without a loss of consciousness ( ...

cardiac MRI Cardiac magnetic resonance imaging (cardiac MRI, CMR), also known as cardiovascular MRI, is a magnetic resonance imaging (MRI) technology used for non-invasive assessment of the function and structure of the cardiovascular system. Conditions in wh ...

, cardiac CT,

heart catheterization Cardiac catheterization (heart cath) is the insertion of a catheter into a chamber or vessel of the heart. This is done both for diagnostic and interventional purposes. A common example of cardiac catheterization is coronary catheterization tha ...

electrophysiology study A cardiac electrophysiology study (EP test or EP study) is a Invasiveness of surgical procedures, minimally invasive procedure using catheters introduced through a vein or artery to record electrical activity from within the heart. This electric ...

echocardiogram Echocardiography, also known as cardiac ultrasound, is the use of ultrasound to examine the heart. It is a type of medical imaging, using standard ultrasound or Doppler ultrasound. The visual image formed using this technique is called an echo ...

, and extensive blood work, and possibly a

sleep study A sleep study is a test that records the activity of the body during sleep. There are five main types of sleep studies that use different methods to test for different sleep characteristics and disorders. These include simple sleep studies, polysom ...

, a cardiologist may rule out a heart condition. Often a

psychiatric evaluation Psychological evaluation is a method to assess an individual's behavior, personality, cognitive abilities, and several other domains. A common reason for a psychological evaluation is to identify psychological factors that may be inhibiting ''a p ...

may follow, as conversion disorder may be suspected in the absence of heart disease or structural heart abnormalities. In the absence of heart abnormalities, the diagnosis is often made on the basis of symptoms. A

gastroenterologist Gastroenterology (from the Greek gastḗr- "belly", -énteron "intestine", and -logía "study of") is the branch of medicine focused on the digestive system and its disorders. The digestive system consists of the gastrointestinal tract, sometime ...

will perform a

colonoscopy Colonoscopy () or coloscopy () is a medical procedure involving the Endoscopy, endoscopic examination of the large bowel (colon) and the distal portion of the small bowel. This examination is performed using either a Charge-coupled device, CCD ...

endoscopy An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are insert ...

, and

abdominal ultrasound Abdominal ultrasonography (also called abdominal ultrasound imaging or abdominal sonography) is a form of medical ultrasonography (medicine, medical application of ultrasound technology) to visualise abdomen, abdominal anatomy, anatomical structu ...

to locate or rule out problems in the abdomen. Determining the cause of Roemheld syndrome is still not an exact science. If you have an ultrasound or sleep study, ensure that you know how to reproduce the symptoms, as it is difficult to detect any abnormalities when symptoms have subsided.

Treatment

Treatment of the primary gastroenterological distress is the first concern, mitigation of gastric symptoms will also alleviate cardiac distress. *

Anticholinergics Anticholinergics (anticholinergic agents) are substances that block the action of the acetylcholine (ACh) neurotransmitter at synapses in the central and peripheral nervous system. These agents inhibit the parasympathetic nervous system by sel ...

magnesium Magnesium is a chemical element; it has Symbol (chemistry), symbol Mg and atomic number 12. It is a shiny gray metal having a low density, low melting point and high chemical reactivity. Like the other alkaline earth metals (group 2 ...

, or

sodium Sodium is a chemical element; it has Symbol (chemistry), symbol Na (from Neo-Latin ) and atomic number 11. It is a soft, silvery-white, highly reactive metal. Sodium is an alkali metal, being in group 1 element, group 1 of the peri ...

(to raise blood pressure) supplements *

Anticonvulsants Anticonvulsants (also known as antiepileptic drugs, antiseizure drugs, or anti-seizure medications (ASM)) are a diverse group of pharmacological agents used in the treatment of epileptic seizures. Anticonvulsants are also used in the treatment ...

have eliminated all symptoms in some Roemheld syndrome sufferers;

Lorazepam Lorazepam, sold under the brand name Ativan, Tavor among others, is a benzodiazepine medication. It is used to treat anxiety (including anxiety disorders), insomnia, severe agitation, active seizures including status epilepticus, alcoh ...

Oxcarbazepine Oxcarbazepine, sold under the brand name Trileptal among others, is a medication used to treat epilepsy. For epilepsy it is used for both focal seizures and generalized seizures. It has been used both alone and as add-on therapy in people with ...

increase GI motility, reduce vagus "noise" (sodium channel blocking believed to contribute to positive effects) *

Alpha blockers Alpha blockers, also known as α-blockers or α-adrenoreceptor antagonists, are a class of pharmacological agents that act as neutral antagonist, antagonists on Adrenergic receptor#.CE.B1 receptors, α-adrenergic receptors (Adrenergic receptor ...

may increase GI motility if that is an issue, also 5 mg to 10 mg

amitriptyline Amitriptyline, sold under the brand name Elavil among others, is a tricyclic antidepressant primarily used to treat major depressive disorder, and a variety of pain syndromes such as neuropathic pain, fibromyalgia, migraine and tension headac ...

if motility is an issue that can't be solved by other methods * Antigas -

simethicone Simeticone (International Nonproprietary Name, INN), also known as simethicone (United States Adopted Name, USAN), is an anti-foaming agent used to reduce bloating, discomfort or pain caused by excessive gas. Medical uses Simeticone is used to ...

, beano, omnimax reduces epigastric pressure *

Antacids An antacid is a substance which neutralizes stomach acidity and is used to relieve heartburn, indigestion, or an upset stomach. Some antacids have been used in the treatment of constipation and diarrhea. Marketed antacids contain salts o ...

calcium carbonate Calcium carbonate is a chemical compound with the chemical formula . It is a common substance found in Rock (geology), rocks as the minerals calcite and aragonite, most notably in chalk and limestone, eggshells, gastropod shells, shellfish skel ...

famotidine Famotidine, sold under the brand name Pepcid among others, is a histamine H2 receptor antagonist medication that decreases stomach acid production. It is used to treat peptic ulcer disease, gastroesophageal reflux disease, and Zollinger–E ...

omeprazole Omeprazole, sold under the brand names Prilosec and Losec, among others, is a medication used in the treatment of gastroesophageal reflux disease (GERD), peptic ulcer disease, and Zollinger–Ellison syndrome. It is also used to prevent up ...

, etc. reduces acid reflux in the case of hiatal hernia or other esophageal type Roemheld syndrome. *

Vagotomy A vagotomy is a surgical procedure that involves removing part of the vagus nerve. It is performed in the abdomen. Types A plain vagotomy eliminates afferent and parasympathetic innervation of the stomach and the left side of the transverse colo ...

, a surgical procedure that involves removing part of the

. *

Beta blockers Beta blockers, also spelled β-blockers, are a class of medications that are predominantly used to manage abnormal heart rhythms (arrhythmia), and to protect the heart from a second heart attack after a first heart attack (secondary prevention). ...

- reduces contractility and automaticity of the heart which reduces irregular rhythms but also lowers blood pressure when symptoms occur, and further reduces

ex:

Carvedilol Carvedilol, sold under the brand name Coreg among others, is a beta blocker medication, that may be prescribed for the treatment of high blood pressure (hypertension) and chronic heart failure with reduced ejection fraction (also known as HFrEF ...

, this will control abnormal heart rhythms, but can precipitate

Prinzmetal angina Variant angina, also known as Prinzmetal angina, vasospastic angina, angina inversa, coronary vessel spasm, or coronary artery vasospasm, is a syndrome typically consisting of angina (cardiac chest pain). Variant angina differs from stable angina ...

and

heart block Heart block (HB) is a disorder in the heart's rhythm due to a fault in the natural pacemaker. This is caused by an obstruction – a block – in the electrical conduction system of the heart. Sometimes a disorder can be inherited. Despite the ...

Etiology

Roemheld syndrome is characterized strictly by abdominal maladies triggering reflexes in the heart. There are a number of pathways through which cardiac reflexes can occur: hormones, mechanical, neurological and immunological.

History

Ludwig Roemheld characterized this particular syndrome shortly before his death; one of his research topics around this time was the effects of calorie intake on the heart. In

Elsevier Elsevier ( ) is a Dutch academic publishing company specializing in scientific, technical, and medical content. Its products include journals such as ''The Lancet'', ''Cell (journal), Cell'', the ScienceDirect collection of electronic journals, ...

publications, there is no current research or publishing under the name Roemheld syndrome, and as a result, many cases go undiagnosed. German publishing on the subject remains untranslated as of 2009.

References

{{DEFAULTSORT:Roemheld Syndrome Syndromes Heart diseases Digestive diseases