PP070 A HICCUPPING HEART: A FORETELL SIGN FOR ACUTE CORONARY SYNDROME

Abstract

Hiccup, is a trivial and self-limiting condition but can progress to persistent or intractable hiccups with serious underlying etiologies including acute coronary syndrome (ACS). We would like to highlight a patient with ACS where hiccup was the only complaint.

59-year-old, gentleman with hypertension presented with persistent hiccups for 2 days. He denied any chest pain, shortness of breath or giddiness. His physical examination was unremarkable, vital signs were stable. He received symptomatic treatment but hiccups persisted. An electrocardiogram (ECG) was ordered unintentionally showing sinus rhythm with significant ST-depressions over leads I, aVL, V2-V6. Because of that, Troponin I was sent and was elevated. Further history, it was exertional-induced hiccups. He was treated for non ST-elevation myocardial infarction and etiological treatment was initiated and his hiccups gradually resolved. He was discharged after 3 days with resolution of ECG changes and cardiac enzymes.

There are various causes of persistent hiccups e.g. metabolic abnormalities, malignancy and central nervous system pathology but rarely attributed to cardiac disease. Cardiovascular hiccups was first described in 1993 by Launois, and to date only 25 articles were found related to it. Our patient’s sole complaint was persistent hiccups aggravated by exertion and was found to have significant ST changes in ECG with raised cardiac enzymes. They resolved upon initiation of etiological treatment suggests the correlation. Risk factor for ACS in our patient was hypertension. The mechanism of cardiovascular hiccups maybe due to irritation of the phrenic nerve, the motor fibers to the diaphragm, which is also the sensory fibers to the pleura and pericardium. The other possible cause could be irritation of the vagus nerve which supplies the pericardium.

Cardiovascular hiccups is rare, but when elderly patients with multiple risk factors for ACS presents with persistent hiccups, it should ignite any treating physician to consider cardiac disease attribution.