WHAT IS ROEMHELD SYNDROME?

Article Updated on 26 April 2022

Between the decades of 1910 and 1920, Dr. Ludwig Roemheld 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 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. Although the precise interactions involved in Roemheld Syndrome are not well-described, anatomical proximity, the vagus nerve (VN) and electrolyte deficiencies are still considered as equally valid candidates for the key element in Roemheld Syndrome, with VN being a well-supported option.      

Roemheld Syndrome is not a disease, 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“ 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. Overall, even patients with the exact conditions to be diagnosed with Roemheld Syndrome, usually aren’t, the connection between the guts and heart symptoms is made, but the syndrome is rarely mentioned.

In this article we’ll examine the available information for Roemheld Syndrome and provide hard facts about its causes, specific symptoms, people at risk, diagnosis, treatment and prevention.

Causes

Since the 1920’s, is well-known that the primary cause of Roemheld Syndrome, is the accumulation of gas in the gastrointestinal (GI) tract. Initially, physicians assumed that those who experienced RS were producing more gas than usual though fermentation (part of the normal processes of digestion), however, as time went on, it became clear that for a great majority of cases, the problem wasn’t the gas produced, but the gas ingested.

A phenomenon called aerophagia (the excessive swallowing of air) seemed to be more pronounced in individuals with Roemheld Syndrome. It’s considered that any condition that promotes aerophagia will also increase the risk for Roemheld Syndrome.

The gas is “the problem” that leads to RS, however, for someone to develop this condition, the vagus nerve is key. If this nerve can be easily overstimulated by the stress in the GI tract then is much more likely for the heart’s rate of pulsations per minute to become affected (normally decreasing to then increase rapidly). Considering this, a pre-existing or easily producible vagotonic condition could also be considered as a cause (or at least a main contributing factor) for Roemheld Syndrome.

Pathologies known to promote Roemheld Syndrome, include:

• Lactose intolerance
• Abnormal gallbladder function
• Hiatal hernia
• Enteric disease
• Loss of the ability to burp (Aneructonia)
• Bowel obstruction
• Acute pancreatic necrosis

Symptoms

Roemheld Syndrome, can manifest in several different ways, these are the most common symptoms reported by patients.

• Sinus Bradycardia (slow heart rate)
• Shortness of Breath
• Chest tightness
• Muscle cramping
• Dizziness
• Palpitations
• Belching, nausea
• Arrhythmia (irregular heart beat)
• Tachycardia (rapid heart rate)
• Panic attacks
• Confusion
• Anxiety
• Depression
• Blood pressure fluctuations
• Lightheadedness
• Vasovagal syncope (fainting)
• Tinnitus (ringing in the ears)
• Fatigue

People at risk

As we mentioned before, aerophagia is an important element in Roemheld Syndrome, and those with this condition will be at a higher risk of developing the syndrome.

Aerophagia is common in people who have the habits of:

• Eating too quickly
• Talking while they eat
• Drinking through straws
• Smoking
• Breathing through their mouths
• Exercising vigorously
• Drinking carbonated beverages
• Wearing loose-fitting dentures

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’re some congestion problems, a lot of air will be swallowed. In general, any need for long-term assisted breathing will increase the risk of aerophagia and Roemheld Syndrome.

In the 1920’s researchers also noticed that those of “nervous predisposition” were more likely to develop symptoms. By today's standards, this means that those struggling with anxiety are also at risk.

People with an overstimulated vagus nerve like 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. People with symphathicotonic conditions will also be vulnerable.

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). Up to 14% of people who suffer from GERD also experience AF.

Diagnosis

Diagnosing Roemheld Syndrome is not easy and due to its nature, many will be misdiagnosed with either a non-existent heart condition or mental issue. Patient’s experiences will vary considerably depending on which doctor they visit first.

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. With that purpose, they’ll 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. If everything goes well, no heart condition will be found.

Some patients are put under psychological examination to detect any signs of anxiety, depression or a conversion disorder. Mainly because their symptoms will appear to have no physical cause.

Gastroenterologists have the best chance of diagnosing RS in symptomatic patients by performing colonoscopies, endoscopies and ultrasounds. This way, a doctor will be able to detect the presence of a gastrointestinal problem (leading to a distended GI tract).

Linking the cardiac symptoms to the GI issues is more difficult. Roemheld Syndrome,  diagnosis at this point is not an exact science and only recently the medical community has started to consider this type of association between the digestive and circulatory systems in the context of treating arrhythmias.

If Roemheld Syndrome is suspected by a doctor, a combination of X-rays and EKGs to detect simultaneous air-filled bowels and arrhythmia has been used for effective diagnosis; However, improvement of cardiac symptoms after treatment of the gastric conditions is the strongest confirmation for Roemheld Syndrome,.  

Treatment

Roemheld Syndrome has no definitive cure but it can be managed by treating its symptoms. The following medications are very helpful for this purpose:

• Anticholinergics or magnesium/ sodium supplements to raise blood pressure
• Anticonvulsants like Lorazepam and Oxcarbazepine help regulate motility in the GI tract and the vagus nerve
• Alpha and beta blockers to increase motility and regulate heart rate respectively
• Antigas to reduce gastric pressure. In this category  Simethicone is very popular
• Antacids help against acid reflux

Some sources mention Vagusectomy as another type of treatment, but we’ve not found information to support this option.

Prevention

A healthier lifestyle and reducing some of the behaviors that lead to gas accumulation in the intestines will help prevent RS.

• Eat slowly and with your mouth closed
• Don't smoke
• If you need assisted breathing, check with your doctor to determine if your equipment is properly calibrated.
• Follow a reduced FODMAP diet. It will help prevent gas accumulation
• Use magnesium supplements and regular exercise to make your heart stronger

To search for the Best Gastroenterologists and Cardiologists in India, London, Thailand and Malaysia,  please use the Mya Care search engine.

References

• Jervell, O., & Lødøen, O. (2009). THE GASTROCARDIAC SYNDROME. Acta Medica Scandinavica, 142(S266), 595-599. doi:10.1111/j.0954-6820.1952.tb13409.x
• Saeed, M., Bhandohal, J. S., Visco, F., Pekler, G., & Mushiyev, S. (2018). Gastrocardiac syndrome: A forgotten entity. The American Journal of Emergency Medicine, 36(8), 1525.e5-1525.e7. doi:10.1016/j.ajem.2018.05.002
• The Gastrocardiac Syndrome. (n.d.). Retrieved from http://emdidactic.blogspot.com/2018/05/the-gastrocardiac-syndrome.html
• Aerophagia: Definition, Treatment, and More. (n.d.). Retrieved from https://www.healthline.com/health/aerophagia#causes
• the definition of vagotonic. (n.d.). Retrieved from https://www.dictionary.com/browse/vagotonic
• Sharma, S. (n.d.). Roemheld Syndrome - Gastric Cardia. Retrieved from http://roemheld-syndrome.com/
• Roemheld syndrome. (2019, February 24). Retrieved from https://www.patientslikeme.com/conditions/roemheld-syndrome
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• Bugiardini, R., Pozzati, A., Ottani, F., Morgagni, G. L., & Puddu, P. (1993). Vasotonic angina: A spectrum of ischemic syndromes involving function abnormalities of the epicardial and microvascular coronary circulation. Journal of the American College of Cardiology, 22(2), 417-425. doi:10.1016/0735-1097(93)90045-3
• Cook, I. J. (2006). Clinical disorders of the upper esophageal sphincter. GI Motility online. doi:10.1038/gimo37
• Roman, C., Varannes, S. B., Muresan, L., Picos, A., & Dumitrascu, D. L. (2014). Atrial fibrillation in patients with gastroesophageal reflux disease: A comprehensive review. World Journal of Gastroenterology, 20(28), 9592-9599. doi:10.3748/wjg.v20.i28.9592
• Linz, D., Hohl, M., Vollmar, J., Ukena, C., Mahfoud, F., & Böhm, M. (2016). Atrial fibrillation and gastroesophageal reflux disease: the cardiogastric interaction. Europace, euw092. doi:10.1093/europace/euw092
• Suguayani. (2018, 9). Roemheld syndrome. Retrieved from http://yourpressinfo.blogspot.com/2018/06/roemheld-syndrome.html
• Dr sanjay gupta cardiologist: Roemheld Syndrome, Stomach Issues Can Cause Heart Problem And Arrhythmia. (n.d.). Retrieved from https://www.keepandshare.com/doc8/19893/drsanjayguptacardiologist-roemheld-syn
• What is a FODMAP diet?. Retrieved from https://www.alimmenta.com/dietas/fodmap/

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