AN ATYPICAL PRESENTATION: BELCHING AS A CHIEF COMPLAINT IN AORTIC STENOSIS-RELATED ANGINA T Dao, MD; J Edavettal, MD Department of Medicine, Louisiana State University Health Sciences Center, Lafayette, LA INTRODUCTION Angina pectoris classically presents as a substernal squeezing chest pain associated with exertion and 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. CASE A 69-year-old man with tobacco abuse presented to internal medicine clinic with a 6-month history of abdominal bloating and episodic belching. He denied nausea or vomiting, but reported a sensation of dysphagia without weight loss. He denied 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 resolve his symptoms. Esophagogastroduodenoscopy was showed no esophageal abnormalities. Biopsies were negative for H pylori. A systolic murmur was heard on exam prompting an echocardiogram which showed an ejection fraction of 65%, 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 surgical aortic valve replacement evaluation. 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, belching may be observed as early symptom of angina warranting further investigation.
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