Gastrocardiac Syndrome: Causes, Symptoms, and Treatment

Roemheld syndrome, also known as gastrocardiac syndrome or gastro heart syndrome, describes a group of symptoms triggered by excessive gas accumulation in the gastrointestinal tract. This syndrome primarily concerns heart complaints, especially chest tightness and chest pain. It is named after Ludwig von Roemheld, who between 1910 and 1920, studied the phenomenon in which patients suffering from digestive problems and no detectable heart issues would experience cardiac symptoms. By the 40's, his research received more attention, and the medical community would eventually accept the existence of a gastro-cardiac symptom complex, also known as the Roemheld Syndrome (RS).

The term "syndrome" does not describe an independent disease but summarizes a group of symptoms that occur under one generic term. Roemheld syndrome primarily concerns discomfort of the chest and heart, the trigger of which can be found in the gastrointestinal tract.

Understanding Roemheld Syndrome

Roemheld syndrome (RS), also known as Roemheld-Techlenburg-Ceconi-Syndrome or gastric-cardia, is a complex of gastrocardiac symptoms first described by Ludwig von Roemheld (1871-1938). He was the first researcher to explore how stomach and heart health correlate. For example, a patient might report gastrointestinal reflux at the same time as a low heart rate (arrhythmia).

The most common model known for Roemheld Syndrome involves some gastrointestinal problem or disease that leads to arrhythmia or other types of abnormal heart rate issues. Roemheld Syndrome is not a disease; it is just a particular combination of symptoms appearing together being caused by one or more pathologies.

Although in the first publications discussing this phenomenon several authors (including Roemheld himself) mention how “frequent“ it was to see patients with gastrointestinal diseases presenting RS, very little information about this syndrome’s epidemiology is available today. In fact, observing Roemheld Syndrome, personally seems to be so rare that a big portion of all modern publications on this topic tend to be case studies about individual patients.

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Causes of Gastrocardiac Syndrome

The main cause for the development of the symptoms is excessive accumulation of gases in the stomach and intestines. Since the 1920’s, it is well-known that the primary cause of Roemheld Syndrome, is the accumulation of gas in the gastrointestinal (GI) tract. A phenomenon called aerophagia (the excessive swallowing of air) seemed to be more pronounced in individuals with Roemheld Syndrome. Diseases that lead to an increased production of intestinal gases can trigger Roemheld syndrome.

The increased volume of the gastrointestinal tract leads to displacement of the diaphragm towards the chest cavity. When healthy, the diaphragm, which lies under the lungs and is the most important component of the respiratory muscles, provides a natural partition wall between the chest cavity and the abdominal cavity. If it is displaced in the direction of the chest cavity, the space that the lungs and heart have to constrict at the same time is reduced. The heart can no longer beat regularly, which leads to the typical cardiac symptoms. Shortness of breath occurs due to the elevated position of the diaphragm, which exerts pressure on the lungs. Hot flashes are a consequence of impaired cardiac function, which triggers the activation of the autonomic nervous system, specifically the sympathetic nervous system responsible for the "fight or flight" response.

When Ludwig von Roemheld first described the syndrome, he observed that the symptoms were not rooted in cardiac issues but rather in the gastrointestinal tract.

Intestinal gases arise mainly from the fact that food components are digested by the bacteria found in the intestine (intestinal flora). As a by-product or end product of this process, gases such as methane, carbon dioxide or hydrogen sulfide are released.

Specific Conditions and Factors

1. Food Intolerance: Food intolerance is often associated with increased gas production by intestinal bacteria. Important examples include lactose intolerance and gluten intolerance (celiac disease). Since the body cannot absorb milk sugar in the case of lactose intolerance, it is increasingly converted by the bacteria in the intestinal flora. Intestinal gases are produced as breakdown products, which can lead to flatulence (meteorism) and gas (winds).
2. Gastrointestinal Inflammation: If there is an inflammation of the stomach (gastritis) or inflammation of the entire gastrointestinal tract (gastroenteritis), digestive gases may also be produced more frequently in the intestine.
3. Hiatal Hernia: The term hiatal hernia describes the relocation of part of the stomach from the abdominal to the chest cavity. The diaphragm has an opening through which the esophagus can reach from the chest cavity into the abdominal cavity and thus into the stomach (Hiatus oesophagus). It can happen that part of the stomach slips through this opening and is thus moved into the chest cavity.
4. Irritable Bowel Syndrome (IBS): Patients with irritable bowel syndrome are also at higher risk of developing Roemheld syndrome. Since irritable bowel syndrome is a complex disease that includes various triggers and influencing factors, it is particularly difficult to pinpoint the exact cause of the occurrence of Roemheld syndrome. However, an increased accumulation of gases in the gastrointestinal tract is also responsible for Roemheld symptoms in irritable bowel patients.
5. Aerophagia: In the 1920’s, researchers also noticed that those of “nervous predisposition” were more likely to develop symptoms. People with an overstimulated vagus nerve, such as those with vasotonic angina will have the right conditions to manifest the syndrome; however, very little is known about the precise vagotonic conditions that could be related to higher or lower risk. Pathologies that lead to weakness of the superior esophageal sphincter (like cricopharyngeal fibrosis) can also increase the risk for Roemheld Syndrome, since they allow more air to enter the GI tract. A good example of this is the link that seems to be between gastroesophageal reflux disease (GERD) and atrial fibrillation (AF).
6. Respiratory Issues: People with respiratory problems who use medical equipment to alleviate their condition are also at risk. Sleep apnea is a good example; usually, this condition requires the patient to use a Continuous Positive Airway Pressure Machine (CPAPM) in the form of a mask. If the air pressure being generated by the machine is not properly calibrated or there are some congestion problems, a lot of air will be swallowed.
7. Mechanical Factors: Mechanically induced Roemheld syndrome is characterized by pressure in the epigastric and left hypochondriac region. Often the pressure is in the fundus of the stomach, the esophagus or distention of the bowel.

Symptoms of Roemheld Syndrome

A variety of symptoms can occur as part of Roemheld syndrome. During this condition, people undergo symptoms related to both the heart and the stomach. Often, the problem roots in the stomach and later affects the heart. Though it can be confused with other conditions, a comprehensive analysis helps in proper diagnosis. Generally, the symptoms vary based on the condition’s severity level and cause.

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The most important include a number of heart problems that resemble the symptoms of angina pectoris (chest tightness). This leads to heartburn-like pain that mainly occurs behind the breastbone. In addition, patients describe tightness in the area of the heart as if constant pressure is being exerted on the heart. In real angina pectoris, which is mainly caused by changes in the coronary arteries, the pain often radiates to the left arm, the shoulders and the lower jaw.

Common symptoms include:

• Heartburn-like pain behind the breastbone
• Tightness in the chest
• Acid reflux and bloating
• Nausea
• Chest pain
• Irregular heartbeat (tachycardia and arrhythmia)
• Depression, anxiety, and panic attacks
• Palpitations and sweating
• Dizziness and fatigue
• Shortness of breath
• Fluctuating blood pressure

It is believed this leads to elevation of the diaphragm, and secondary displacement of the heart. The cranium dysfunction mechanical changes in the gut can compress the vagus nerve at any number of locations along the vagus, slowing the heart. This is complemented by gastro-coronary reflexes whereby the coronary arteries constrict with "functional cardiovascular 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 detected. This can actually trigger a heart attack in people with cardiac structural abnormalities i.e. If the heart rate drops too low for too long, catecholamines are released to counteract any lowering of blood pressure. Catecholamines bind to alpha receptors and beta receptors, decreasing vasodilation and increasing contractility of the heart.

Diagnosis of Roemheld Syndrome

Diagnosing Roemheld Syndrome is not easy, and due to its nature, many will be misdiagnosed with either a non-existent heart condition or a mental issue. There is significant scope of misdiagnosis of Roemheld syndrome.

Roemheld syndrome is a so-called diagnosis of exclusion. This means that if a Roemheld syndrome is suspected, the doctor will try to rule out possible diseases of the heart. The diagnosis of RS usually starts with a cardiac workup, as the gastric symptoms may go unnoticed, the cardiac symptoms are scary and can be quite severe. Diagnosis is often made based on symptoms in the absence of heart abnormalities. Determining the cause of Roemheld syndrome is still not an exact science.

Since the most obvious symptoms of Roemheld Syndrome are very similar to those belonging to many different cardiac diseases, most patients will visit a cardiologist first. Most doctors will focus on finding a heart problem that is not really there.

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Diagnostic Steps:

1. Cardiac Evaluation: In order to rule out heart diseases, in addition to a detailed survey of the person concerned (anamnese) a heart monitor is used. With that purpose, they will use diagnostic tools like EKG’s, Holter monitors, slope tests, cardiac MRIs, cardiac CTs, cardiac catheterizations, EP studies, Echocardiograms, and many blood tests. Sleep studies may even be included. In addition, the patient receives an electrocardiogram (EKG) to assess the activity of the heart.
2. Gastroenterological Evaluation: Gastroenterologists have the best chance of diagnosing RS in symptomatic patients by performing colonoscopies, endoscopies, and ultrasounds. Linking the cardiac symptoms to the GI issues is more difficult.
3. Psychological Evaluation: Some patients are put under psychological examination to detect any signs of anxiety, depression, or a conversion disorder.

It is common to misdiagnose gastrocardiac syndrome as the symptoms synch with many other health problems. This is why early imaging is the key to efficient health maintenance. Commonly, the first step in diagnosing the condition is to rule out any other cardiac problems. For this, you are advised to undergo scans like cardiac CT, cardiac MRI, ECG, AI-supported cardiac exams, and other laboratory tests. Later, when heart issues are absent, the medical professionals may advise other diagnostic tests for the gut. These might include abdominal ultrasound, colonoscopy, and endoscopy.

Roemheld syndrome is sometimes misdiagnosed as an anxiety disorder because its symptoms, such as palpitations and chest discomfort, can overlap with those of anxiety.

Treatment of Roemheld Syndrome

Roemheld Syndrome has no definitive cure, but it can be managed by treating its symptoms. The treatment of Roemheld syndrome symptoms is directed at the trigger.

Treatment Approaches:

1. Dietary Changes: If a food intolerance is the cause of the increased gas production, a change of diet can bring relief from symptoms. It is recommended to use a food diary to determine the meals after which the symptoms appear. In this way the exact trigger can be identified and avoided. This process should be supported by trained experts. We have developed a nutritional therapy program, with your personal nutritionist, which is tailored to your symptoms. We also provide a digital nutrition diary to help you track your daily diet and symptoms. Follow a reduced FODMAP diet.
2. Medications: Antigas to reduce gastric pressure. In severe cases, the doctor can prescribe the medications dimethicone or simethicone (e.g. Dimeticon works as a defoaming agent and is used for the therapy for gas accumulations in the gastrointestinal tract. Antacids - calcium carbonate, famotidine, omeprazole, etc. Antacids - nexium, tums, Pepcid AC, rolaids, etc.
3. Treating Underlying Conditions: If the symptoms are caused by inflammation of the gastrointestinal tract, usually the inflammation subsides, which improves the symptoms. Because of many inflammations in the gastrointestinal tract are caused by viruses, antibiotics do not help. A hiatal hernia that causes discomfort can be corrected with surgery.
4. Lifestyle Adjustments: Gas accumulation in the gastrointestinal tract is lowered by adopting a healthier lifestyle and cutting out on certain habits. Lifestyle Incorporate physical activity into your daily routine. It not only helps the heart but also maintains overall wellness. Avoid alcohol, drugs, and smoking, as they are all detrimental to gut and heart health. Also, keep yourself hydrated because it aids in smooth digestion and reduces stomach discomfort.
5. Home Remedies: Many patients also report that home remedies such as anise, fennel and caraway tea or swollen psyllium husks can help remove excess air in the intestine and relieve discomfort.
6. Surgical Interventions: LINX Magnetic Sphincter Augmentation: LINX magnetic sphincter augmentation is a minimally invasive surgery that involves strengthening the lower esophageal sphincter by implanting a ring of magnetic beads. This device helps to enhance sphincter function and prevent reflux. By reducing gastroesophageal reflux, the procedure can alleviate symptoms related to Roemheld Syndrome. Fundoplication Surgery: Fundoplication is another surgical intervention aimed at treating GERD, which often coexists with Roemheld Syndrome. This surgery reinforces the sphincter between the esophagus and stomach by wrapping the upper stomach around the esophagus, preventing acid reflux.

Additional Management Strategies:

• Probiotics: Incorporating probiotics into the diet can improve gut health and reduce symptoms associated with Roemheld Syndrome.
• Smaller, Frequent Meals: Replace large meals with smaller, frequent meals - Overeating or consuming large portions can increase the pressure on the diaphragm and digestive system, leading to more pronounced symptoms.

Vagus Nerve Stimulation (VNS): VNS is a treatment that involves stimulating the vagus nerve to manage symptoms. Excessive gas can overstimulate the vagus nerve, which regulates heart rate and digestion, potentially causing cardiac symptoms.

Potential Complications of Untreated Roemheld Syndrome

Untreated or poorly managed Roemheld Syndrome may have potential long-term implications and complications. Chronic or recurrent episodes of excessive gas, bloating, and abdominal discomfort can lead to decreased quality of life and ongoing digestive issues. In some cases, persistent gas can contribute to esophageal or gastric reflux, potentially causing erosion or damage to the lining of the esophagus. Additionally, prolonged episodes of gas and bloating can result in malnutrition due to decreased appetite and poor nutrient absorption.

Roemheld syndrome may cause chest pain and palpitations that resemble a heart attack, but it does not actually cause one. It is essential to differentiate between cardiac issues and Roemheld syndrome. Sleep apnea can exacerbate Roemheld syndrome. Roemheld syndrome is not typically fatal, but if left unmanaged, it may lead to serious complications such as severe arrhythmias that can become life-threatening.

Ongoing Research and Future Treatments

It is worth noting that medical research is continually evolving, and new treatment approaches may be explored in the future. Gastroenterologists and researchers may investigate the efficacy of medications that can alleviate symptoms, such as antacids, prokinetics, or drugs targeting specific mechanisms of excessive gas production. Non-medication strategies, such as specialized diets or probiotic interventions, may also be areas of research interest.

Lifestyle and Prevention

Vigorous activities, such as weightlifting, can significantly increase intra-abdominal pressure, potentially leading to stomach compression. This, in turn, may push gastric contents upward into the esophagus, triggering acid reflux.

Yes, stress and anxiety can exacerbate Roemheld syndrome symptoms. Stress can heighten vagus nerve sensitivity, which in turn may worsen gastrointestinal distress.

Diet Gastrocardiac syndrome is better managed with a few modifications in the diet. Patients are often encouraged to avoid carbonated drinks, fried, fatty, and too much junk food. These are more difficult to digest and may slow stomach emptying, resulting in elevated gas production. Additionally, instead of overconsuming large meals, divide small, frequent meals throughout the day. Moreover, probiotics in the diet can enhance gut health and alleviate symptoms of roemheld syndrome. Examples of fermented foods rich in probiotics are yogurt and kefir.

Case Studies

The following examples are real-life cases that affirm the connection between gastrointestinal disorders and cardiac symptoms:

Case 1

A 62-year-old woman complained about heart palpitations which were worsening with time. Along with that, she reported shortness of breath and dizziness. Importantly, she noticed that her symptoms escalated with food intake. To rule out other conditions, she underwent a cardiovascular exam which appeared normal except for arrhythmia. Moreover, she had a history of GERD and hernia, and her ultrasounds approved it. Once the doctors treated her hernia, she reported that her arrhythmia and palpitations resolved completely.

Case 2

In another study, a woman complained of symptoms that matched Roemheld syndrome. She suffered from gastric distension and dizziness. Consequently, these led to extreme sinus bradycardia. Upon resolving the gastric distension, her cardiac issues eventually subsided.

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