ST-Segment Elevation Myocardial Infarction with Acute Stent Thrombosis Presenting as Intractable Hiccups: An Unusual Case

Abstract

Patient: Male, 51Final Diagnosis: ST-segment elevation myocardial infarction with acute stent thrombosisSymptoms: Chest pain • hiccupsMedication: —Clinical Procedure: —Specialty: CardiologyObjective:Unusual clinical courseBackground:Acute coronary syndrome (ACS) can present with atypical chest pain or symptoms not attributed to heart disease, such as indigestion. Hiccups, a benign and self-limited condition, can become persistent or intractable with overlooked underlying etiology. There are various causes of protracted hiccups, including metabolic abnormalities, psychogenic disorders, malignancy, central nervous system pathology, medications, pulmonary disorders, or gastrointestinal etiologies. It is rarely attributed to cardiac disease.Case Report:We report a case of intractable hiccups in a 51-year-old male with cocaine related myocardial infarction (MI) before and after stent placement. Coronary angiogram showed in-stent thrombosis of the initial intervention. Following thrombectomy, balloon angioplasty, and stent, the patient recovered well without additional episodes of hiccups. Although hiccups are not known to present with a predilection for a particular cause of myocardial ischemia, this case may additionally be explained by the sympathomimetic effects of cocaine, which lead to vasoconstriction of coronary arteries.Conclusions:Hiccups associated with cardiac enzyme elevation and EKG ST-segment elevation before and after percutaneous coronary intervention (PCI) maybe a manifestation of acute MI with or without stent. The fact that this patient was a cocaine user may have contributed to the unique presentation.

Persistent Hiccups as the Only Presenting Symptom of ST Elevation Myocardial Infarction

“…In a case reported by Davenport et al in 2012, similar to our case, the patient presented with persistent hiccups without any other complaints; however, the patient was found to have inferior wall NSTEMI, and a subsequent cardiac catheterization revealed significant stenosis of the left circumflex and first obtuse marginal coronary arteries [9]. Zhang et al reported a case of persistent hiccups with chest pain in a patient with cocaine-induced inferior wall STEMI with 99% occlusion of the mid-RCA and 80% stenosis of the LAD artery [4]. …”

“…Any irritants in the reflex pathway, such as physical, chemical, inflammatory, or neoplastic process, can trigger hiccups. Most commonly, persistent hiccups are caused by the nervous system disorder, either central (neoplastic and inflammatory) or peripheral by irritation of the phrenic nerve (goiter) or irritation of the vagus nerve (otolaryngologic diseases, meningitis, esophageal, stomach, and duodenal diseases, hepatitis, pancreatitis, and enteritis) [4]. …”

Atypical Presentation of Acute Coronary Syndrome and Importance of Wellens’ Syndrome

“…Other sites of referred pain are the mandible, temporomandibular joint, ears, neck, and teeth [ 5 ]. Hiccups, a rare presenting symptom, was reported in a patient with PCI (percutaneous coronary intervention)-related STEMI [ 7 ].…”

Myocardial Ischemia Presenting with Hiccups

“…6,18 Of the myocardial infarction group, one patient each was diagnosed with Dressler syndrome, 16 associated with ischemic cardiomyopathy and atrial fibrillation, 15 and had in-stent thrombosis of the right coronary artery. 29 In one patient, myocardial infarction was chronic with a 4-year medical history, 15 and another patient had a 2-year history of myocardial infarction with an acute onset at current presentation. 26 Except for these two patients, all remaining patients had AMI.…”

“…The underlying etiology was myocardial infarction in 127 (98.4%) patients, 5,[7][8][9][10][11][12][13][14][15][16][17][19][20][21][22][23][24][25][26][27][28][29] and myocardial ischemia in 2 (1.6%) patients. 6,18 Of the myocardial infarction group, one patient each was diagnosed with Dressler syndrome, 16 associated with ischemic cardiomyopathy and atrial fibrillation, 15 and had in-stent thrombosis of the right coronary artery.…”