International Journal of Cardiology 184 (2015) 369–370

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International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard

Letter to the Editor

An extremely rare presentation of supraventricular tachycardia: Burping Ertan Yetkin Middle East Hospital Division of Cardiology, Mersin, Turkey

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Article history: Received 13 January 2015 Accepted 24 February 2015 Available online 27 February 2015 Keywords: Gastroesophageal reflux disease Supraventricular tachycardia AVNRT Radiofrequency ablation Eletrophysiological study

1. Introduction Palpitation (including pulsation in the neck), chest discomfort, dyspnea, hyperventilation, lightheadedness and anxiety are the most common types of symptoms of supraventricular tachycardia. Less frequent symptoms are chest pain diaphoresis, nausea and syncope. Occasionally they may have no symptoms [1,2]. Paroxysmal chest pain attacks, and absence seizure like symptoms due to supraventricular tachycardia have been recently published in literature [3,4]. In terms of definitive diagnosis and treatment modalities, documentation of the arrhythmia has a critical importance [5]. Catheter ablation has become a wellestablished, first-line therapy for atrioventricular nodal reentrant tachycardia (AVNRT) [1,6]. Although AVNRT induction at the time of electrophysiological study (EPS) is considered the typical indication for performing a slow pathway modification procedure [1], individual approaches regarding the diversity and severity of patient symptoms should be taken into consideration while making decisions [4]. Here we present a supraventricular tachycardia case presented with burping or eructation, chest discomfort and dyspnea paroxysms initially diagnosed and treated as gastroesophageal reflux disease (GERD). 2. Case A 45-year-old man presented with complaints of burping and chest discomfort. He had been suffering from these complaints for two years. His attacks were told to occur paradoxically several times in a month E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ijcard.2015.02.090 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.

mainly at the rest position. The patient's detailed history revealed that episodes of burping or eructation had a sudden onset and termination pattern lasting 5–10 min. Dyspnea and chest discomfort were the accompanying symptoms with eructation. He had been prescribed anti-acid and proton pump inhibitor drugs for the diagnosis of gastroesophageal reflux disease. His abdominal ultrasonographic and endoscopic examination had been reported to be normal. On his cardiac examination blood pressure and heart rate were within the normal range. There were no abnormal findings on 12 lead surface electrocardiography and echocardiography. He had also angiographically proven normal coronary arteries which was performed in another center 6 months ago. Twenty four hour Holter monitoring did not reveal any abnormal conduction system abnormalities. When he was asked if he has any complaints after the termination of eructation episodes, he confirmed the presence of dizziness, lightheadedness and polyuria lasting a few hours. He was otherwise a healthy man. Then the patient was scheduled for electrophysiological study in our lab to rule out arrhythmia as an underlying etiology. His sinus and AV node functions and AV conduction velocities were found to be normal. However programmed atrial and ventricular stimulation documented the presence of dual AV (slow–fast) node physiology. Then empirical slow pathway catheter ablation was performed successfully at the inferoseptal region close to the tricuspid annulus. Afterwards the patient was given acetylsalicylic acid 300 mg daily for one month. He had never experienced any burping or chest discomfort attacks until the end of the 6 month follow-up period. 3. Discussion Gastroesophageal reflux disease (GERD) is an upward displacement of stomach fluids into the esophagus, which leads to certain symptoms or damage to the esophagus, and is the most common gastrointestinal diagnosis made during visits to outpatient clinics [7]. Heartburn and acid regurgitation sometimes accompanied by chest pain and dysphagia are the most common symptoms [8]. Symptoms such as getting bloated, feeling of heaviness, burping, and burning sensation in throat are the frequently asked symptoms of GERD [9]. In our case the main symptom was eructation accompanied by chest discomfort and dyspnea mimicking GERD. Therefore that patient underwent a serial gastrointestinal examination and endoscopic evaluation. At first glance, it is unnecessary to make a differential diagnosis including arrhythmia. However absence of improvements in symptoms and no documented etiology made the patient to be referred to the cardiology department. Indeed the paradoxical nature of eructation chest discomfort attacks and the presence of dizziness and lightheadedness

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after termination were the symptoms pointing out to arrhythmia as an underlying etiology. To the best of our knowledge, this is the first case of supraventricular tachycardia mimicking GERD in literature. On the other hand, in recent years, an association between GERD and atrial fibrillation has been proposed [10–13]. This association has been partially explained by the close positioning of the left atrium and esophagus. Overstimulation of the vagus nerve induced by GERD is another postulated mechanism [14]. In our case the mechanism seems to be the other way around. During the paroxysm of eructation, supraventricular tachycardia is the likely triggering event either through the cardiac afferent fibers on the inferoseptal region of the right ventricle or via the pericardial irritation of the vagus nerve during the tachycardia. This case underlines the importance of a high suspicion index for the diagnosis of cardiac arrhythmias as an underlying etiology especially in undetermined symptoms presenting itself in a paroxysmal pattern. Conflict of interest

[2] [3] [4] [5]

[6] [7] [8]

[9] [10]

The authors report no relationships that could be construed as a conflict of interest.

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An extremely rare presentation of supraventricular tachycardia: Burping.

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