Title: An atypical presentation: Belching as a chief complaint in aortic stenosis-related angina
Author: Tristan Dao, MD; John Edavettal, MD; University Hospital and Clinics, LSUHSC Lafayette
Background: Angina pectoris classically presents as a substernal squeezing chest pain associated with exertion, often related to coronary atherosclerotic disease. Occasionally, there can be atypical presenting symptoms including nausea, vomiting, and diaphoresis. Although gastrointestinal symptoms have been described in angina pectoris, high suspicion for cardiac etiology must be maintained due to potentially detrimental outcomes due to delayed diagnosis. Here we detail an unusual presentation of severe aortic stenosis. Case Presentation: A 69-year-old Caucasian male with a history significant for tobacco abuse presented to internal medicine clinic with a 6-month history of abdominal bloating and episodic belching. He denied any nausea or vomiting, but reported a sensation of dysphagia without weight loss. He denied any chest pain but reported discomfort with exertion and meals that were relieved with belching, causing some food aversion. EKG showed no conduction, rhythm, ST segment or T wave abnormalities. At the time he was started on esomeprazole for treatment of gastroesophageal reflux which initially provided relief but eventually did not improve his symptoms. Given his concerning presentation and smoking history an esophagogastroduodenoscopy was performed, which showed no esophageal abnormalities, biopsies of mild gastritis were negative for H pylori. A systolic murmur was heard on exam, prompting an echocardiogram which showed an ejection fraction of 65%, but showed aortic stenosis with a dilated left atrium, an aortic valve area of 0.86 cm 2 and a peak velocity of 3.42m/s. He was referred to cardiology for evaluation for surgical aortic valve replacement. A coronary angiogram showed 70% stenosis of an ostial lesion in the circumflex artery. He underwent a coronary artery bypass as well as a surgical bioprosthetic aortic valve replacement. At 6-week follow up he reports that his symptoms have largely resolved including his belching symptoms. Discussion: Although uncommon, belching and dysphagia can be concerning for esophageal disease but cardiac pathology must be maintained on the differential. In a patient with cardiac risk factors and gastrointestinal symptoms that resolved with surgical intervention, the presence of belching as an early symptom of angina warrants further investigation.
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