S McLean, J Preston, AD Flapan
The Royal Infirmary of Edinburgh and Penicuik Medical Centre
Correspondence to: scott.mclean@luht.scot.nhs.uk
SMJ 2008 53(4): 10
Introduction
Belching is a symptom of myocardial ischaemia in a number of patients1,2. Smith & Carley3 (2001) stated that “It should not be assumed that patients who have both chest pain and belching are more likely to be suffering from a non-cardiac cause.” (p.467)
This case report describes a previously well 59-year-old man whose symptoms of coronary ischaemia manifested as eructation (belching), and were relieved by the deployment of intra-coronary stents to the Left Anterior Descending coronary artery.
Case History
The patient initially presented to the General Practicioner (GP) complaining of a week long history of severe belching. Over a five month period he had nine GP consultations and described frequent, forceful belching which interrupted normal speech and conversation. The symptoms began to disrupt sleep and make him reluctant to spend time in the company of others. There were no red flag gastrointestinal symptoms, but he did admit to four units of alcohol per day. He denied chest pain, but did describe a “pressure/bloated” feeling in the upper chest which was relieved by belching.
The patient tested positive and was treated for Helicobacter Pylori and stopped his non-steroidal anti-inflammatory drug. He was advised to reduce his alcohol intake and was prescribed Gaviscon/Ranitidine and then Lansoprazole (30mg once daily). Although there was some temporary improvement over for weeks severe symptoms returned and he was referred for upper gastrointestinal endoscopy.
While waiting for gastrointestinal investigations the patient again presented to the GP. Belching was still his main complaint, but on further questioning he admitted to a vague anterior chest discomfort which was worse on exertion and associated with a significant increase in the frequency of belching. Serum total cholesterol was found to be 7.2mmol (non-fasting).
The patient was referred to the Rapid Access Chest Pain Clinic (RACPC), where he was seen within 24 hours.
On arrival at the RACPC, a routine resting 12-lead ECG showed signs of a recent anterior wall myocardial infarction (Biphasic T wave inversion with 1mm ST segment elevation in precordial leads V2 to V4).
2D Echocardiography showed normal left ventricular size with hypokinesis of the apex and apical intraventricular septum. Overall left ventricular systolic function was preserved. Although the echocardiogram supported the diagnosis of recent anterior myocardial infarction, a functional assessment was thought necessary to assist with risk stratification.
The patient underwent a Bruce protocol exercise (treadmill) test. He managed 4 minutes 20 seconds before the test was discontinued due to ST segment elevation of 2-3mm in leads V1 to V3, with reciprocal ST segment depression in leads II, III and aVF. From 2 minutes 30 seconds onwards, the patient experienced very frequent belching. This abated in the recovery phase following the test.
Immediate admission to the cardiology ward was arranged. Within 2 hours the patient underwent coronary arteriography. This demonstrated mild diffuse 3-vessel coronary artery disease with a total occlusion of the Left Anterior Descending (LAD) artery from the mid-portion. Following angioplasty balloon inflation, one 3x32mm drug-eluting stent and one 3.5x18mm bare-metal stent were deployed with an excellent arteriographic result. The patient was returned to the ward, had an uncomplicated post-procedure recovery and was discharged home the following morning on Aspirin 75mg daily, Clopidogrel 75mg daily (12 months), Simvastatin 40mg daily, Bisoprolol 1.25mg daily, Ramipril 10mg daily and GTN spray.
At follow-up 3 weeks later the patient reported a significant reduction in symptoms of belching. He was able to report only 3-4 single episodes per day, in contrast with his description of 250-300 daily episodes previously. He was undertaking a daily 2 mile walk with neither symptoms of belching nor chest tightness.
Conclusion
Belching has been cited as being commonly associated with angina1-3. The striking features of this case are the gradually evolving correlation of symptoms with exertion, the gravity of the findings of a recent anterior myocardial infarction/blocked LAD artery, and relief of symptoms following the deployment of intracoronary stents.
REFERENCES
Darsee JR. Eructonesius with inferior myocardial infarction. N Engl Med J 1978;298:221-222.
Logan RL, Wong F, Barclay J. Symptoms associated with myocardial infarction: are they of diagnostic value? NZ Med J1986;99:276-278.
Smith J, Carley S. Belching as a symptom of myocardial ischaemia. Emerg Med J 2001;18:467.