Chloe-heart Syndrome
Chloe-heart syndrome refers to a disease characterized by cardiac discomfort and electrocardiogram (ECG) abnormalities caused by biliary tract diseases (mainly cholelithiasis, acute and chronic cholecystitis). It was first proposed by Babcock in 1909.
The severity of cardiac discomfort is positively correlated with the severity of biliary tract diseases and can be alleviated with the remission of biliary tract diseases. It presents clinical manifestations similar to angina pectoris and coronary heart disease (such as acute coronary syndrome), making it easy to be misdiagnosed clinically. A ten-year literature review analysis in China (2004-2014) indicated that more than half of the patients with Chloe-heart syndrome were misdiagnosed as angina pectoris or other heart diseases[1].
Pathogenesis
Currently, the more widely accepted theories include the biliary tract nerve reflex theory ([[biliary-heart reflex]]), infection and poisoning, electrolyte and acid-base imbalance theory, and biliary tract-cardiac endocrine theory.
Cardiovascular Clinical Manifestations
- Precordial pain – The nature of the pain is similar to angina pectoris, characterized by a dull pain in the precordial area. Unlike simple angina pectoris, the duration of Chloe-heart syndrome pain is relatively long. It mostly occurs after a full meal, or after eating high-fat foods, and during lying down at night. Oral nitroglycerin and similar drugs do not relieve the pain, but atropine and pethidine can alleviate it. The precordial pain disappears after treatment of the biliary tract disease. The ineffectiveness or poor efficacy of oral nitrate drugs is an important feature of this disease (some nitrates also seem ineffective in certain coronary heart diseases
).
Arrhythmia – After the onset of biliary tract disease, palpitations and heart flutters may occur because acetylcholine released by the vagus nerve causes myocardial activity disorders, mostly manifesting as sinus arrhythmia. Arrhythmias may disappear after biliary tract diseases are cured.
ECG Changes – ECG abnormalities can be observed, with more than 30% of patients showing nonspecific ST segment elevation or depression. Clinically, it is very difficult to distinguish these ECG changes from those caused by myocardial ischemia.
Digestive System Clinical Manifestations
Chest and abdominal pain – The pain is mainly dull and vague, with rare stabbing or colicky pain. The pain is mostly located in the right upper abdomen and precordial area. The pain duration is relatively long, and it is more pronounced after eating. Physical signs may include tenderness in the upper abdomen and sub-xiphoid region (+), and a positive Murphy’s sign (+).
Nausea and vomiting – Some patients experience poor appetite, nausea, and vomiting, with vomitus generally containing gastric contents or mixed with yellow-green fluid.
What biliary tract diseases can cause Chloe-heart syndrome?
- Cholelithiasis
- Acute and chronic cholecystitis
Differential Diagnosis
This disease needs to be differentiated from angina pectoris and myocardial infarction.
Differentiation points are as follows:
- Onset time: Chloe-heart syndrome patients often have a history of biliary tract disease or recurrent upper abdominal pain, and symptoms mostly occur after eating or when lying down to rest. Angina pectoris and myocardial infarction are often triggered by emotional agitation or physical exertion; cold, emotional agitation, and exertion can also trigger angina and myocardial infarction.
- Pain location: Chloe-heart syndrome pain is mostly in the right upper abdomen and is accompanied by digestive symptoms such as poor appetite, nausea, and vomiting.
- Relief method: Chloe-heart syndrome pain lasts longer, and oral nitrate treatment is ineffective or less effective, while antispasmodic and analgesic drugs can relieve the pain. After the biliary disease symptoms are relieved, ECG changes basically return to normal. Angina pectoris pain is shorter and can be relieved after coronary intervention.
- ECG abnormalities: Chloe-heart syndrome ECG changes are mostly transient and return to normal after abdominal pain resolves. Acute coronary syndrome is often accompanied by changes in troponin and myocardial enzymes, and acute myocardial infarction shows persistent ECG changes.
Treatment
Once Chloe-heart syndrome appears, the key is timely management of the heart issues.
In addition to treating infection and spasms caused by gallbladder diseases, preventive treatment of myocardial ischemia should be carried out to prevent malignant arrhythmia and cardiac arrest. Patients with coronary heart disease should actively treat the coronary heart disease to improve coronary blood supply and prevent the worsening of biliary tract diseases from exacerbating coronary heart disease symptoms.
Reference Framework
References
Yang Shixian, Wu Tieyong, Liu Xiaogang. Analysis of 220 Misdiagnosed Cases of Chloe-heart Syndrome [J]. Journal of PLA Medical, 2015, 27(6): 63-65. ↩︎