BRIEF OBSERVATION Anemia and ischemia: Myocardial injury in patients with gastrointestinal bleeding Fabio Bellotto, MD, a Stefano Fagiuoli, MD, b Andrea Pavei, MD, a Shawn A. Gregory, MD, c Arianna Cati, MD, a Elisabetta Silverj, MD, b Mario Plebani, MD, d Martina Zaninotto, PhD, d Tommaso Mancuso, MD, b Sabino Iliceto, MD a a Department of Clinical Cardiology, and b Department of Gastroenterological and Surgical Sciences, University of Padua, c Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, and d Laboratory Medicine, University of Padua, Italy. Acute gastrointestinal bleeding can produce hypovole- mia, hypotension, and diminished oxygen-carrying capac- ity, causing myocardial ischemia and necrosis. Activation of the sympathetic nervous system can further increase myo- cardial oxygen demand and worsen ischemia. These pro- cesses would be expected to be most important in patients with obstructive coronary artery disease, a group that is also at risk for gastrointestinal bleeding. 1,2 Studies examining the relationship between gastrointestinal bleeding and myo- cardial ischemia suggest that the prevalence of acute myo- cardial infarction in patients with gastrointestinal hemor- rhage ranges from 1 to 14%. 1-3 Cardiac troponins are highly specific and sensitive markers of myocardial injury. 6-8 However, there has been no systematic study using troponin to define myocardial injury in patients with acute gastrointestinal bleeding and anemia. Prior studies that included patients with acute anemia and myocardial injury, defined by troponin ele- vation, were designed to evaluate patients hospitalized with any critical illness. 9,10 Furthermore, there is no general agreement about risk stratification of myocardial injury in patients with acute upper gastrointestinal bleed- ing. There is some suggestion that those with a greater number of coronary risk factors, a history of coronary artery disease, a lower blood pressure on admission, older age, severe illnesses, and/or lower hemoglobin are at greater risk of myocardial infarction. 1-5 The aim of the present study is to examine the rela- tionship between hemoglobin and the risk of myocardial injury, defined as an elevation of troponin I, in patients with anemia secondary to upper gastrointestinal bleeding and no other clinical signs or symptoms of coronary insufficiency on enrollment. These findings and other possible predictors of myocardial injury were examined during the hospitalization. Materials and methods In this prospective study we enrolled 227 consecutive patients admitted to the gastroenterology ward with upper gastrointestinal bleeding. All patients had hematemesis, me- lena, or bleeding during esophagastroduodenoscopy and hemoglobin 14 g/dL for men and 12 g/dL for women. None of the patients exhibited clinical signs or symptoms of coronary insufficiency on admission. All had serial mea- surements of cardiac troponin I (RxL Dimension, Dade Requests for reprints should be addressed to Fabio Bellotto, MD, Department of Cardiology, Padua General Hospital, University of Padua Medical School, Via Giustiniani 2, 35128 Padova, Italy. E-mail address: fabio.bellotto@unipd.it. 0002-9343/$ -see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.amjmed.2005.01.026 The American Journal of Medicine (2005) 118, 548 –551