Reply to Dr. Garcia-Cano

We read with interest the letter by Garcia-Cano, and we are pleased to see that other endoscopists share this field of interest.

The possible relationship between the stress of an endoscopic retrograde cholangiopancreatography (ERCP) procedure and the occurrence of cardiovascular events after the endoscopy has also been discussed in earlier reports. Such events are clinically evident, although they are rare in any endoscopy unit.

The pathophysiological mechanisms precipitating myocardial ischemia are still unclear. The ischemia is most often [1], but not only [2], related to tachycardia. It is not linked with hypoxemia [2] or coronary artery disease (unpublished observations). However, tachycardia may be connected with the mechanical stress of the ERCP or the use of antiperistaltic drugs (butylscopolamine) [2]. Myocardial infarction has been reported earlier in connection with ERCP [1].

The present case of post-ERCP pulmonary edema may have been due to myocardial ischemia (or myocardial infarction) during and following ERCP, but evidence of this is not clearly given in the letter. The patient was taking nitrates daily due to ischemic heart disease and had a history of atrial fibrillation, pre-ERCP morbidities that would certainly reduce the cardiac/ischemic tolerance level, with myocardial ischemia and infarction as potential consequences. However, the patient was admitted due to cholangitis and might have been overhydrated, due to signs of circulatory collapse before ERCP. This is not clear from the letter.

The patient might possibly have benefited from treatment with a beta-blocking agent a few hours before the ERCP [1] - if, of course, the blood-pressure level had made this possible.

References

• 1 Rosenberg J, Overgaard H, Andersen M. et al . Double blind randomized controlled trial of effect of metoprolol on myocardial ischaemia during endoscopic retrograde cholangiopancreatography.  BMJ. 1996;  313 258-261
• 2 Christensen M, Reinert R, Rasmussen V. et al . Factors affecting heart rate variability during endoscopic retrograde cholangio-pancreatography (ERCP).  Eur J Surg. 2003;  168 546-551