What is the recommended diagnostic and treatment approach for Roemheld (gastro‑cardiac) syndrome?

Roemheld Syndrome: Diagnostic and Treatment Approach

Roemheld syndrome is a gastrocardiac condition where gastrointestinal distention mechanically compresses the heart and stimulates the vagus nerve, triggering cardiac symptoms such as palpitations, chest pain, and arrhythmias—diagnosis requires excluding primary cardiac disease followed by demonstration of symptom improvement with gastrointestinal therapy. 1

Diagnostic Approach

Initial Cardiac Exclusion (Mandatory First Step)

• Perform 12-lead ECG to rule out primary cardiac pathology, particularly in patients presenting with chest pain and palpitations. 2
• Obtain cardiac biomarkers (troponin T or I) to exclude acute myocardial injury, as gastrointestinal chest pain can mimic angina pectoris. 2
• 24-48 hour ambulatory ECG monitoring should be performed to characterize any arrhythmias (commonly supraventricular tachycardia or premature ventricular contractions in Roemheld syndrome). 3, 4
• Stress testing or coronary angiography is reasonable when symptoms persist despite negative initial workup, particularly in patients with cardiovascular risk factors. 2

Critical pitfall: Do not assume gastrointestinal etiology without first excluding life-threatening cardiac causes—the symptoms overlap substantially and misdiagnosis can be fatal. 2, 5

Gastrointestinal Evaluation (After Cardiac Exclusion)

• Detailed symptom timing: Document the temporal relationship between food intake, postprandial bloating, and onset of cardiac symptoms (palpitations typically occur during or immediately after meals in Roemheld syndrome). 1, 3
• Upper endoscopy (EGD) should be performed to identify hiatal hernia, gastroesophageal reflux disease, esophagitis, or other structural abnormalities that can cause gastric distention and cardiac compression. 2, 3, 4
• High-resolution esophageal manometry evaluates for motility disorders (achalasia, esophageal spasm) that may contribute to gastric distention. 2, 3
• pH monitoring (24-96 hour Bravo test) quantifies acid reflux burden when gastroesophageal reflux disease is suspected as the underlying trigger. 2, 3

Proposed IKMAIR Diagnostic Criteria

The following criteria improve diagnostic accuracy for Roemheld syndrome 1:

• Cardiac symptoms (chest pain, palpitations, dyspnea) temporally associated with gastrointestinal symptoms (bloating, postprandial fullness, belching)
• Documented arrhythmias on ECG monitoring that correlate with gastrointestinal distention
• Absence of primary cardiac disease after comprehensive cardiac workup
• Identifiable gastrointestinal pathology (hiatal hernia, GERD, excessive gas, gallstones)
• Symptom improvement following gastrointestinal-directed therapy

Treatment Algorithm

Conservative Management (First-Line)

• Empiric acid suppression therapy with proton pump inhibitors for 4-8 weeks is reasonable when gastroesophageal reflux is suspected and upper endoscopy shows no alarm features. 2
• Dietary modifications: Small, frequent meals; avoidance of gas-producing foods (legumes, carbonated beverages); reduction of fat intake to decrease gastric distention. 1
• Lifestyle adjustments: Elevate head of bed, avoid recumbency immediately after meals, weight reduction if obese. 1
• Pharmacologic adjuncts: Prokinetic agents (metoclopramide) for gastroparesis; simethicone for excessive gas; antispasmodics for esophageal dysmotility. 1

Surgical Intervention (Definitive Treatment)

Surgical correction is indicated when conservative management fails and a structural abnormality (hiatal hernia) is identified as the underlying cause. 3, 4

• Robotic-assisted hiatal hernia repair with fundoplication or magnetic sphincter augmentation (LINX) resolves both gastrointestinal and cardiac symptoms in patients with documented hiatal hernia and Roemheld syndrome. 3
• Complete resolution of arrhythmias has been documented 4 months post-operatively, with patients able to discontinue proton pump inhibitors. 3
• Mechanism of benefit: Surgical repair eliminates mechanical compression of the heart by the herniated stomach and reduces vagal nerve stimulation from the anatomically displaced gastric fundus. 3, 4

Prognosis and Follow-Up

• Variable prognosis depends on the underlying etiology—patients with correctable structural abnormalities (hiatal hernia) have excellent outcomes with surgical repair. 1, 3
• Recurrent symptoms despite negative cardiac workup warrant extended ambulatory monitoring and repeat gastrointestinal evaluation, as the diagnosis is often missed initially. 2
• Long-term monitoring: Patients should be followed with periodic symptom assessment and repeat ECG if arrhythmias were initially documented. 1

Key clinical pearl: The anatomical proximity of a herniated gastric fundus to the anterior vagal nerve creates direct physical stimulation that is a more potent trigger for arrhythmias than reflux alone—this explains why surgical correction is often curative when medical management fails. 3