C0732 - Hiatal Hernia-Induced Non-ST Elevation Myocardial Infarction (NSTEMI): A Unique Complication of Hiatal Hernia

Dushyant S. Dahiya, MD¹, Amandeep Singh, MD², Fnu Nivedita, MBBS³, Rajat Garg, MD², Abhilash Perisetti, MD⁴, Sailaja Pisipati, MBBS, FRCS⁵, Manik Aggarwal, MD², Haseeb Mohideen, MD⁶, Madhu Vennikandam, MD⁷, Sumant Inamdar, MD, MPH⁸, Mohammad Al-Haddad, MD, MSc⁶, Madhusudhan Sanaka, MD^9
1Central Michigan University College of Medicine, Saginaw, MI; ²Cleveland Clinic Foundation, Cleveland, OH; ³Kasturba Medical College, Manipal, Manipal, Karnataka, India; ⁴Parkview Cancer Institute, Fort Wayne, IN; ⁵Mayo Clinic, Scottsdale, AZ; ⁶Indiana University School of Medicine, Indianapolis, IN; ⁷Sparrow Hospital/Michigan State University College of Human Medicine, Lansing, MI; ⁸University of Arkansas for Medical Sciences, Little Rock, AR; ⁹Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH

Introduction: Hiatal Hernia (HH) is characterized by the displacement of abdominal viscera into the mediastinum. It is usually an incidental finding on imaging or endoscopy, but may present with non-specific clinical signs and symptoms, often linked to gastroesophageal reflux disease (GERD). However, some patients may develop cardiac complications secondary to the direct compressive effects of a large HH. We describe a unique case of HH leading to Non-ST Elevation Myocardial Infarction (NSETMI) in an elderly female.

Case Description/Methods: A 90-year-old female with a past medical history of GERD presented to the emergency department (ED) for worsening nausea, vomiting, and epigastric abdominal pain for the past 3 days. She described the abdominal pain as sharp, severe, non-radiating, and associated with vomiting consisting undigested food particles without blood. She noted worsening of her abdominal pain 30 minutes after oral intake and on lying down shortly after meals. She denied prior abdominal surgeries. However, she admitted to increasing use of over-the-counter antacids for symptomatic relief of her GERD. On clinical evaluation, she was hemodynamically stable. However, abdominal examination elicited mild tenderness in the epigastric region. A chest x-ray in the ED showed the presence of a large hiatal hernia (Figure 1). Laboratory investigations revealed elevated troponin level of 0.721 ng/mL and electrocardiograph demonstrated new T-wave inversions in leads V5 and V6. She was given aspirin, atorvastatin, ticagrelor, metoprolol, pantoprazole and started on a heparin infusion. Cardiology was consulted and a diagnosis of HH-induced NSTEMI was established. A nasogastric tube (NGT) was inserted for decompression and led to a downtrend in troponin levels. She was deemed a poor candidate for cardiac catheterization and HH repair by cardiology and cardiothoracic surgery due to her advanced age. She was eventually discharged home on appropriate medications, and outpatient cardiology and gastroenterology follow-up.

Discussion: To our knowledge, this is one of the few cases of HH-induced NSTEMI reported in literature. Per the American College of Cardiology guidelines, these patients should be given aspirin, ticagrelor, metoprolol, and heparin to reduce myocardial oxygen demand. Additionally, decompression via NGT may result in decreased cardiac compression by the large HH. Furthermore, in select patients, HH repair may be a viable treatment option to treat the underlying cause and prevent further episodes.



Disclosures:


Dushyant S. Dahiya, MD¹, Amandeep Singh, MD², Fnu Nivedita, MBBS³, Rajat Garg, MD², Abhilash Perisetti, MD⁴, Sailaja Pisipati, MBBS, FRCS⁵, Manik Aggarwal, MD², Haseeb Mohideen, MD⁶, Madhu Vennikandam, MD⁷, Sumant Inamdar, MD, MPH⁸, Mohammad Al-Haddad, MD, MSc⁶, Madhusudhan Sanaka, MD⁹. C0732 - Hiatal Hernia-Induced Non-ST Elevation Myocardial Infarction (NSTEMI): A Unique Complication of Hiatal Hernia, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.