Hiccups as an Atypical Presentation of Cardiac Disease
Maanit Kohli, MD
Saint Peter’s University Hospital, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
A 77-year-old man presented to the emergency department (ED) with concern for persistent hiccups of 5 days’ duration. The man reported that the lack of relief over time had resulted in his having difficulty performing daily activities and sleeping comfortably, which eventually had caused him to feel extremely lethargic and fatigued. He reported that the hiccups were associated with difficulty swallowing, discomfort while breathing during severe bouts, and heartburn. He had contacted his primary care provider about these symptoms and had been advised to go to the ED.
History. The patient reported having no chest pain, dyspnea, or palpitations. His medical history was significant for coronary artery disease, for which he had undergone coronary artery bypass grafting 18 years prior. He also had a history of hyperlipidemia, hypertension, and diabetes. His most recent hospitalization had been a month ago for treatment of back pain; he had been discharged to a subacute rehabilitation facility after symptomatic treatment.
Physical examination. At presentation, he had a blood pressure of 113/69 mm Hg, a pulse rate of 154 beats/min, a temperature of 36.5°C, a respiratory rate of 17 breaths/min, and an oxygen saturation of 96% on 2 L/min of oxygen via nasal cannula. He appeared to be in no acute distress, with no jugular venous distention and no carotid artery bruits or visible pulsations over the carotid artery area. Cardiac examination findings included an irregular pulse and normal heart sounds without rubs, murmurs, or gallops. Respiratory examination revealed good bilateral air entry without any crackles. No edema was observed over the extremities.
Diagnostic tests. An electrocardiogram revealed atrial flutter with variable atrioventricular block and left bundle branch block (LBBB), with a ventricular rate of 112 beats/min (Figure). On further review, the LBBB was discovered to be chronic. There was no evidence of ST-segment elevation or depression.
Laboratory tests disclosed the following values: hemoglobin, 15.1 g/dL (reference range, 13-17 g/dL); hematocrit, 45.6% (reference range, 40%-56%); platelet count, 254 × 103/µL (reference range, 150-400 × 103/µL); blood urea nitrogen, 35 mg/dL (reference range, 9-28 mg/dL); creatinine, 1.32 mg/dL (reference range, 0.66-1.25 mg/dL); sodium, 133 mEq/L (reference range, 136-145 mEq/L); potassium, 5.4 mEq/L (reference range, 3.5-5.1 mEq/L); magnesium, 1.5 mEq/L (reference range, 1.3-2.2 mEq/L); and troponin T, 0.11 ng/mL (reference range, 0.03-0.12 ng/mL).
Treatment and outcome of the case. He was started on diltiazem and heparin infusions. His hyperkalemia was reversed with the administration of calcium gluconate, insulin, and dextrose. Overnight, he reverted to sinus rhythm; the next day, he was started on oral anticoagulation along with oral diltiazem. His troponin leak was presumed to be secondary to the atrial flutter and was observed to be decreasing on subsequent checks. Echocardiography done during his hospitalization did not reveal any worsening of cardiac function compared with previous evaluations. He was discharged in stable condition on oral anticoagulation and rate-control medications.
Discussion. Although hiccups are a common transient condition that may be thought of as innocuous, occasionally they may be a symptom of a more serious underlying condition. Hiccups are divided into 3 categories based on duration: brief, a bout lasting up to 48 hours; persistent, lasting from 48 hours to 1 month; and intractable, lasting longer than 1 month.1
The exact mechanism that provokes hiccups is unknown, but the neuronal pathway of the afferent limb, a central mediator, and the efferent limb has been well described.2 Usually caused by gastric distention, hiccups are rarely implicated in cardiac disorders such as myocardial infarction and pericarditis.3-5
- Kolodzik PW, Eilers MA. Hiccups (singultus): review and approach to management. Ann Emerg Med. 1991;20(5):565-573.
- Samuels L. Hiccup: a ten year review of anatomy, etiology, and treatment. Can Med Assoc J. 1952;67(4):315-322.
- Ng JL-L, Aziz EF, Herzog E. Electrocardiogram for hiccups? Am J Med. 2011;124(3):e5-e6.
- Krysiak W, Szabowski S, Stępień M, Krzywkowska K, Krzywkowski A, Marciniak P. Hiccups as a myocardial ischemia symptom. Pol Arch Med Wewn. 2008;118(3):148-151.
- Doshi H, Vaidyalingam R, Buchan K. Atrial pacing wires: an uncommon cause of postoperative hiccups. Br J Hosp Med (Lond). 2008;69(9):534.