Management of Oesophageal Spasm with Elevated Troponin

Initial Assessment and Diagnosis

The American College of Cardiology and European Heart Society recommend excluding acute coronary syndrome (ACS) through serial troponin measurements, ECG monitoring, and clinical assessment, as oesophageal spasm is a diagnosis of exclusion that can only be considered after ruling out life-threatening cardiac causes of chest pain and troponin elevation 1, 2
Obtain a 12-lead ECG within 10 minutes of presentation to identify ST-elevation MI or ischemic changes, as recommended by the American College of Cardiology and European Heart Journal 1, 2
Measure cardiac troponin (I or T) immediately at presentation and repeat at 3-6 hour intervals to establish a rising/falling pattern characteristic of acute myocardial injury, according to the European Heart Journal and American College of Cardiology guidelines 2, 3
Place the patient in an environment with continuous ECG monitoring and defibrillation capability, as recommended by the American College of Cardiology 1
A rising and/or falling troponin pattern with at least one value above the 99th percentile indicates acute myocardial necrosis and requires management as NSTEMI, as stated by the European Heart Journal and Praxis Medical Insights 2, 3

Oesophageal disorders, including oesophageal spasm, are recognized in the differential diagnosis of chest pain with troponin elevation, according to the European Heart Journal 4
Type 2 myocardial infarction can occur from supply-demand mismatch if the patient develops tachycardia, hypertension, or severe pain-related stress during oesophageal spasm episodes, as reported by the European Heart Journal and Praxis Medical Insights 2, 3

If troponin is rising/falling with ischemic ECG changes, manage as NSTEMI - initiate dual antiplatelet therapy, anticoagulation, and consider early invasive strategy within 24 hours for high-risk features, as recommended by the American College of Cardiology and European Heart Journal 1, 2
If troponin is mildly elevated (<2-3 times upper limit) with stable pattern, consider Type 2 MI from tachycardia, hypertension, or other stressors during pain episodes, and obtain echocardiography to assess for structural heart disease, according to the European Heart Journal and Praxis Medical Insights 2, 3, 5
Serial troponin measurements every 3-6 hours are essential - stable elevations suggest chronic myocardial injury rather than acute ACS, as stated by Praxis Medical Insights and the European Heart Journal 3, 2

Coronary artery spasm can cause transient complete occlusion with ST-elevation and troponin release, mimicking both ACS and oesophageal spasm clinically, as reported by the European Heart Journal 6
Provocative testing with ergonovine may be considered in patients with recurrent chest pain at rest, negative stress testing, and non-obstructive coronary arteries on angiography to detect coronary vasospasm, according to the European Heart Journal 6, 7
The diagnosis of oesophageal spasm should prompt consideration that the patient may have had Type 2 MI from pain-induced tachycardia or hypertension, requiring optimization of cardiovascular risk factors despite normal coronary arteries, as recommended by the European Heart Journal and Praxis Medical Insights 2, 3