(P24) Gastrocardiac Syndrome: A Rare Emergency Department Presentation

Chief Complaint : A 66-year-old white male physician presented to the emergency department with a complaint of multiple episodes of near-syncope upon swallowing food.

History of Present Illness : The patient had a history of right bundle branch block and bradycardia that were asymptomatic, migraine headaches for which he took rizatriptan and Excedrin, acid reflux, and a small hiatal hernia. During his evaluation he also reported that he was a heavy coffee drinker and an avid consumer of citrus fruits. He was physically active for his age and had lost 10 kg through exercise over 4 months. He had gone to a restaurant for dinner and upon swallowing his first mouth full of food he noticed his heart rate became rapid and he had near syncope. This occurred several times during the meal and every meal thereafter for seven days. He reported his heart rate as 150 beats per minute during the episodes, which lasted very briefly—only until the food bolus passed into the stomach. Liquids did not cause symptoms. He underwent cardiac and gastrointestinal work-ups.

Pertinent Physical Exam: This 80 kg, 69 cm male, had a BP of 145/90 mmHg, pulse 55/min with a regular rhythm (he had a RBBB and bradycardia since age 17). There were no murmurs appreciated. Lungs were clear to auscultation, and had a respiratory rate of 12 breaths per minute. All other systems were unremarkable.

Pertinent Laboratory Data: His basic metabolic panel showed no abnormalities and his CXR was normal. ECG revealed a RBBB and bradycardia of 50. Transthoracic echocardiography revealed an ejection fraction of 65%, mild aortic regurgitation, and no wall motion abnormalities. Cardiac catheterization revealed a 50% obstruction in the left anterior descending, circumflex, right, and OM1 arteries. A thirty-day Holter monitor demonstrated multiple episodes of wide complex supraventricular tachycardia, none more than 12 beats. Endoscopy demonstrated multiple areas of inflammation in the fundus of the stomach—and a wide complex tachycardia occurred with endoscope insertion. He was not tested for Helicobacter pylori.

Case Discussion: Gastrocardiac syndrome was first reported by Ludwig von Roemfeld who first described the associated cardiac symptomatology with gastric pathology in 1913. He was able to instigate arrythmias with esophageal stimulation. Gastrocardiac syndrome can result in bradycardia or premature ventricular contractions (PVCs), rapid rates such as wide complex supraventricular tachycardias or atrial fibrillation. Wide complex supraventricular tachycardias may be difficult to distinguish form ventricular tachycardia (figure 1). This syndrome, whose origin has not been definitively determined, is related to gastroesophageal reflux (GERD), hiatal hernia, gastric and/or intestinal distension. In some individuals, obesity, obstructive sleep apnea, and inflammatory bowel disease have been postulated as sources.

GERD is associated with autonomic imbalance from increased vagal tone causing arrhythmogenicity (figure 2). Large hiatal hernias can cause compression of the left atrium and posterior ventricular wall, as well as pulmonary vein compression leading to dyspnea. GERD can also cause a reduction in coronary blood flow from esophageal acid stimulation which can lead to ischemia that generates PVCs. Beta-blockers, PPIs, and anti-foaming agents can be used as treatment, but, at times, a cardiac catheter ablation is required. This syndrome is essentially a rare, yet forgotten entity.

This patient had several of the aforementioned risk factors. He was treated with a change of diet (decreased citrus and no coffee), metoprolol XL 25 mg daily, and a proton pump inhibitor (PPI). He had resolution of symptoms at 45 days. At 6 months the metoprolol and PPI were discontinued with no recurrence of symptoms.

References and Acknowledgements (Optional): Roemfeld L. Der gastro-kardiale symptomenkomplex, eine besondere form sog. Herzneurose Fortschr Med, 1913;3:57.

Hofmann R, Bäck M. Gastro-cardiology: A novel perspective for the gastrocardiac syndrome. Front Cardiovasc Med 2021. 8:764478. doi: 10.3389/fcvm.2021.764478.

Mehta A, Bath A, Ahmed UM, Kalavakuna JK. Rare and unusual presentation of the gastrocardiac syndrome. BMJ Case Rep, Dec 17 2022;13(12): e236910. doi: 10.1136/bcr-2020-236910.

Saeed M, Bhandohal JS, Visco F, Pekler G, Mushiyev S. Gastrocardiac syndrome: A forgotten entity. Am J Emerg Med 2018; 36: 1525.e5-1525.e7.

Qureshi K, Naeem N, Saleem S, Chaudhry MS, Pasha F. Recurrent episodes of paroxysmal supraventricular tachycardia triggered by dyspepsia: A rare case of gastrocardiac syndrome. Cureus 2021, Oct 18;13(10):e18857. doi: 10.7759/cureus_18857.ecollection 2021.