More on the association of acute cholecystitis and cardiovascular disease

Sir, As a corollary to the association of troponinosis and acute cholecystitis,1 there is report of the near-doubling of total serum creatine phosphokinase (albeit within the normal range as in one autopsy-validated case of myocardial infarction)2 in a 63-year-old woman who, in addition, had constricting retrosternal pain, and new-onset of ST segment elevation amounting to 3–4 mm in leads V1–V3, thereby justifying thrombolytic therapy.3 Subsequent angiography, however, revealed neither coronary heart disease nor coronary artery spasm, and the eventual diagnosis was that of acute cholecystitis complicated by Klebsiella pneumoniae septicaemia.3 Also in keeping with the documentation of cholecystitis-related cardiac conduction disturbance1 is the report of a 48-year-old woman in whom an attack of acute cholecystitis was complicated by two syncopal episodes, and documentation of third degree atrioventricular block, while awaiting cholecystectomy. Subsequent to that procedure, the following tests, namely, electrophysiological testing, 48-h electrocardiography (ECG), exercise ECG, carotid sinus massage, echocardiography and coronary angiography, were entirely unremarkable.4 Gall bladder-associated conduction disturbances, however, are not confined to the acute inflammatory phase of gall bladder disease. The most extreme manifestation of conduction disturbance, namely, asystolic cardiac arrest, can occur even in the absence of acute inflammation when the gall bladder is manipulated during attempted laparoscopic cholecystectomy, as was the case in a 70-year-old man with no past history of ischaemic heart disease. In that example, following three episodes of asystolic cardiac arrest, each associated with manipulation of the gall bladder, the operation was abandoned, but subsequent electrophysiological investigations did not reveal a primary cardiac event as the cause of the asystolic episodes, and the isoenzyme profile was negative for myocardial injury. Successful laparoscopic cholecystectomy was subsequently performed after insertion of a prophylactic temporary pacemaker.5 Conversely, major cardiac surgery can inflict major ischaemic injury on the gall bladder, as in those instances of acute acalculous cholecystitis that are attributable to cardiac bypass surgery.6,7