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Sinus bradycardia with hiatus hernia
Sinus bradycardia with hiatus hernia Peter Marks, M.B., Ch.B., M.R.C.P. J . G. B . T h u r s t o n ,
M.B., M.R.C.P.
London, England
Three
patients
were seen who had
sliding and paraesophageal ciated with intermittent cases the bradycardia
hiatus
large mixed hernias
sinus bradycardia.
assoIn all
was abolished by atropine
pointing to vagal mediation. In no case did the arrhythmia recur after surgical repair of the hernia. report
These since
cases are sinus
considered
bradycardia
has
worthy not
of
been
recorded in association with hiatus hernia.
C a s e reports Case 1. The patient, a 65-year-old man, was admitted to hospital with pain in the left hypochondrium intermittently, radiating into the left arm. The pain was unaffected by exercise but was brought on by adopting the supine position. He complained also of water brash and this was related to food. being particularly severe after a large meal. It was relieved by antacids and polymethylsiloxane. This symptom complex had been present for 3 years but had become progressively worse, especially in the last 3 months before presenration. In addition, for the 6 months prior to admission he complained Of intermittent attacks of dizziness also precipitated by lying down. It had been noticed by a medical attendant that his pulse rate had dropped to 40 during one of these attacks. The patient had complained of dizziness but there was no syncope. Examination on admission revealed no abnormalities save some eplgastric tenderness. The cardiovascular system was normal. Both resting and exercise electrocardiograms (ECG's} were blameless, of normal axis. and in sinus rhythm. There was no postural hypotension. Serum biochemistry was normal tOO.
Barium swallow was performed and showed gross reflux with a large mixed sliding and paraesophageal hiatus hernia (Fig. 1 }. Stomach and duodenum were normal. Esophagoscopy showed esophagitis and much regurgitation but there was no stenosis or tumour. During his stay in hospital preoperatively, of 6 days' duration, he had 16 attacks of bradycardia which were always precipitated by lying down. The ECG presented in Fig. 2 From Westminster Hospital, London. England. Received for publication Sept. 22. 1975. Reprint requests: Dr. Peter Marks. Senior House Officer. CoronaryCare Unit. Westminster Hospital. Dean Ryle St.. Horseferry Rd.. London SWlP 2AP. England.
30
Fig. 1. Case 1. Barium swallow showing a large mixed Sliding and paraesophageal hiatus hernia. shows a trace during one of these attacks, the rate being 40 beats per minute, and the ECG presented in Fig. 3 sbows his normal rate (75 beats per minute). The rate was fixed at40 per minute and was unaffected by exercise in the erect position but atropine caused it to increase. On very few occasions the bradycardia persisted on his reaching the standing position. During these times the chest x=ray showed that the hiatus hernia remained trapped within the chest. After 20 minutes the rate returned to normal and the chest x-ray showed t h a t the hernia was reduced. This sequence was demonstrated some five times before operation. At operation an extremely large hiatus hernia was discovered and repaired. Postoperative recovery was uneventful and the pulse rate remained consistently in his normal range of 80 per minute. No episodes of bradycardia have been experienced by the patient in over 18 months of follow-up. Case 2. The patient was a 52-year-old woman who experienced transient episodes of sinus bradycardia on adopting the supine position. This was in the total absence of overt c'ardiac disease. Resting and exercise ECG's were normal, as was serum biochemistry. No postural hypotension could be demonstrated. In her case the sinus bradycardia caused no symptoms and was a chance finding by a medical attendant. Four episodes of bradycardia were recorded electrocardiographically while she was in hospital. On one recorded occasion the bradycardia persisted when she assumed the standing
January, 1977, Vol. 93, No. 1, pp. 30-32
Sinus bradycardia with hiatus hernia
Fig. 2. Case 1. ECG showing sinus bradycardia, rate of 40 beats per minute.
position. A chest x-ray was pe~:formed and showed the hiatus hernia trapped within the chest, as shown in Fig. 4. After 10 minutes the rate returned to normal and the chest x-ray showed that the hernia was reduced. At operation a large mixed sliding and paraesophageal hiatus hernia was repaired. Subsequent follow-up has shown no recurrence of the arrhythmia. Case 3, A 56-year-old man presented with gross esophageal reflux. Serum investigations and resting and exercise ECG's were all found to be normal. No postural hypotension could be demonstrated. He had no history of cardiac disease. At esophagoscopy, esophagitis and gross reflux were demonstrated. During the patient's stay in hospital three episodes of sinus bradycardia were recorded, all of which were precipitated by lying down. These attacks were terminated by atropine, which reversed the bradycardia of rate 40 to the normal rate of 76. At operation the patient's large sliding and paraesophageal hiatus hernia {Fig. 5) was repaired and there has been no subsequent recurrence of the arrhythmia.
Fig. 3, Case 1. ECG showing normal rate (75 beats per minute).
Discussion
The majority of hiatus hernias produce no s y m p t o m s . V e r y r a r e l y t h e y m a y p r o d u c e p a i n on effort. O c c a s i o n a l l y t h e y m a y p r o d u c e s u b s t e r n a l o r p r e c o r d i a l d i s c o m f o r t w h e n t h e p a t i e n t is b e n d i n g o r l y i n g on t h e left side. I t is p r o b a b l e t h a t m o s t s y m p t o m s a t t r i b u t e d to h i a t u s h e r n i a s are actually due to reflux esophagitis. Resemb l a n c e s m a y b e d u e t o t h e t r a n s m i s s i o n of p a i n impulses from the esophagus over cord segments which are similar to those carrying pain impulses from the heart. Particularly with large hernias which cause displacement of thoracic structures t h e r e m a y b e d y s p n e a or p a l p i t a t i o n s . A s s o c i a t e d spasm of the diaphragm may produce referred p h r e n i c p a i n in t h e l e f t s h o u l d e r region, a n d t h i s may be projected downward into the arm and be associated with palpitation, thus simulating c a r d i a c disease. C h a n g e s in p o s t u r e c a n p r o d u c e effects on heart rate. Thus, on adopting the supine position c a r d i a c o u t p u t i n c r e a s e s a n d h e a r t r a t e will fall. I n f a c t , u s u a l l y t h i s a c c o u n t s o n l y for a s m a l l r e d u c t i o n in b a s a l r a t e , y i e l d i n g a r a t e a few b e a t s below normal value for a short time. However,
American Heart Journal
Fig. 4. Case 2. Chest x-ray showing hiatus hernia trapped within the chest.
t h e r e a r e c a r d i o v a s c u l a r reflexes w h i c h c a n profoundly affect heart rate and can produce s i g n i f i c a n t b r a d y c a r d i a . T h e s e reflexes a r e init i a t e d b y s t i m u l a t i o n of t h e n e r v e s or n e r v e e n d i n g s in t h e v e n t r i c l e s , left a t r i a , a n d e p i c a r d i u m . S t i m u l a t i o n o f r e c e p t o r s l o c a t e d in t h e e p i c a r d i u m is f a v o r e d a s t h e e x p l a n a t i o n o f p r o d u c t i o n of b r a d y c a r d i a in h i a t u s h e r n i a s . B r i e f o c c l u s i o n of t h e o u t f l o w f r o m t h e c a n n u -
31
Marks and Thurston
Fig. 5. Case 3. Barium swallow showing large sliding and paraesophageal hiatus hernia. lated c o r o n a r y sinus in the open-chest anesthetized dog caused a rise in c o r o n a r y venous pressure a n d b r a d y c a r d i a 2 T h e b r a d y c a r d i a was abolished b y i n t r a v e n o u s atropine. This response was abolished b y c u t t i n g the cervical vagi a n d reversibly abolished by cooling t h e m to less t h a n 7 ~ C, Distension of the left a t r i u m with or w i t h o u t c o n c o m i t a n t p u l m o n a r y venous distension has been found to cause b r a d y c a r d i a in a n e s t h e t i z e d dogs. -~B o t h these m e c h a n i s m s are n o t t h o u g h t to b e r e l e v a n t to the m e c h a n i s m of p r o d u c t i o n of b r a d y c a r d i a in h i a t u s hernias. I t has been found t h a t 25 to t00 t~g of a c e t y l s t r o p h a n t h i d i n to the epicardium of the left ventricle of anesthetized and u n a n e s t h e t i z e d dogs caused bradycardia. 3 T h e response developed after an a*cerage latency of 8 seconds a n d lasted up to 12 minutes. Cooling the cervical vagi to 8 to 10 ~ C. or prior application of 1 per cent procaine hydrochloride to the epicardium o f the h e a r t blocked the response. T h e response was therefore a reflex of the sensory receptors being located in the surface layers of the left ventricle. Electrophysiological recordings f r o m simple and multifiber p r e p a r a t i o n s of the
32
right r e c u r r e n t cardiac nerve show t h a t the receptors for this reflex are t h e m e c h a n o r e c e p t o r s whose fibers b e l o n g to the C group. T h i s was confirmed b y Bergel and Makin, 4 who showed t h a t epicardial s t i m u l a t i o n of the left ventricle with nicotine in open-chest anesthetized dogs produced a fall in h e a r t r a t e m e d i a t e d reflexly b y the vagus. T h e e x t r e m e similarity of t h e changes following epicardial s t i m u l a t i o n to those seen in the fainting reaction, with p a r t i c u l a r reference to bradycardia, raises the possibility of a m o r e t h a n fortuitous resemblance. It m u s t be stressed t h a t none of the three p a t i e n t s h a d at a n y t i m e significant h y p o t e n s i o n or a n y of the o t h e r s y m p t o m s of fainting. F u r t h e r m o r e , the persistence of the b r a d y c a r d i a and the f a c t it disappeared on adopting the erect posture save on those occasions during which the hernia r e m a i n e d within the chest radiologically, points to the pressure effect on epicardial receptors as b e i n g the m o s t likely explanation. T h e fact t h a t the b r a d y c a r d i a was abolished by atropine points to its vagal mediation.
Summary T h r e e cases of large mixed sliding and paraes0phageal h i a t u s hernias are described. T h e s e were associated with episodes of sinus bradycardia. T h e b r a d y c a r d i a was abolished by a t r o p i n e pointing to vagal mediation. After surgical repair of the hernia there was no recurrence of the a r r h y t h m i a . T h e s e cases h a v e been considered w o r t h y of r e p o r t since sinus b r a d y c a r d i a has not been recorded specifically in association with hiatus hernias.
REFERENCES 1. Muers, M. F., and Sleight, P.: The reflex cardiovascular depression caused by occlusion of the coronary sinus in the dog, J. Physiol. 221:259, 1970. 2. Edis, A. J, Donald, D. E., and Shepherd, J. T.: Cardiovascular reflexes from stretch of pulmonary vein-atrial junctions in the dog, Circ. Res. 27:1091, 1970. 3. Sleight, P., Lall, A., and Muers, M.: Reflex cardiovascular effects of epicardial stimulation by acetylstrophanthidin in dogs, Circ. Res. 25:705, 1969. 4. Bergel, D. H., and Makin, G. S.: Central and peripheral cardiovascular changes following chemical stimulation of the surface of the dog's heart, Cardiovasc. Res. 1:80, 1967.
January, 1977, Vol. 93, No. 1
M.B., M.R.C.P.
London, England
Three
patients
were seen who had
sliding and paraesophageal ciated with intermittent cases the bradycardia
hiatus
large mixed hernias
sinus bradycardia.
assoIn all
was abolished by atropine
pointing to vagal mediation. In no case did the arrhythmia recur after surgical repair of the hernia. report
These since
cases are sinus
considered
bradycardia
has
worthy not
of
been
recorded in association with hiatus hernia.
C a s e reports Case 1. The patient, a 65-year-old man, was admitted to hospital with pain in the left hypochondrium intermittently, radiating into the left arm. The pain was unaffected by exercise but was brought on by adopting the supine position. He complained also of water brash and this was related to food. being particularly severe after a large meal. It was relieved by antacids and polymethylsiloxane. This symptom complex had been present for 3 years but had become progressively worse, especially in the last 3 months before presenration. In addition, for the 6 months prior to admission he complained Of intermittent attacks of dizziness also precipitated by lying down. It had been noticed by a medical attendant that his pulse rate had dropped to 40 during one of these attacks. The patient had complained of dizziness but there was no syncope. Examination on admission revealed no abnormalities save some eplgastric tenderness. The cardiovascular system was normal. Both resting and exercise electrocardiograms (ECG's} were blameless, of normal axis. and in sinus rhythm. There was no postural hypotension. Serum biochemistry was normal tOO.
Barium swallow was performed and showed gross reflux with a large mixed sliding and paraesophageal hiatus hernia (Fig. 1 }. Stomach and duodenum were normal. Esophagoscopy showed esophagitis and much regurgitation but there was no stenosis or tumour. During his stay in hospital preoperatively, of 6 days' duration, he had 16 attacks of bradycardia which were always precipitated by lying down. The ECG presented in Fig. 2 From Westminster Hospital, London. England. Received for publication Sept. 22. 1975. Reprint requests: Dr. Peter Marks. Senior House Officer. CoronaryCare Unit. Westminster Hospital. Dean Ryle St.. Horseferry Rd.. London SWlP 2AP. England.
30
Fig. 1. Case 1. Barium swallow showing a large mixed Sliding and paraesophageal hiatus hernia. shows a trace during one of these attacks, the rate being 40 beats per minute, and the ECG presented in Fig. 3 sbows his normal rate (75 beats per minute). The rate was fixed at40 per minute and was unaffected by exercise in the erect position but atropine caused it to increase. On very few occasions the bradycardia persisted on his reaching the standing position. During these times the chest x=ray showed that the hiatus hernia remained trapped within the chest. After 20 minutes the rate returned to normal and the chest x-ray showed t h a t the hernia was reduced. This sequence was demonstrated some five times before operation. At operation an extremely large hiatus hernia was discovered and repaired. Postoperative recovery was uneventful and the pulse rate remained consistently in his normal range of 80 per minute. No episodes of bradycardia have been experienced by the patient in over 18 months of follow-up. Case 2. The patient was a 52-year-old woman who experienced transient episodes of sinus bradycardia on adopting the supine position. This was in the total absence of overt c'ardiac disease. Resting and exercise ECG's were normal, as was serum biochemistry. No postural hypotension could be demonstrated. In her case the sinus bradycardia caused no symptoms and was a chance finding by a medical attendant. Four episodes of bradycardia were recorded electrocardiographically while she was in hospital. On one recorded occasion the bradycardia persisted when she assumed the standing
January, 1977, Vol. 93, No. 1, pp. 30-32
Sinus bradycardia with hiatus hernia
Fig. 2. Case 1. ECG showing sinus bradycardia, rate of 40 beats per minute.
position. A chest x-ray was pe~:formed and showed the hiatus hernia trapped within the chest, as shown in Fig. 4. After 10 minutes the rate returned to normal and the chest x-ray showed that the hernia was reduced. At operation a large mixed sliding and paraesophageal hiatus hernia was repaired. Subsequent follow-up has shown no recurrence of the arrhythmia. Case 3, A 56-year-old man presented with gross esophageal reflux. Serum investigations and resting and exercise ECG's were all found to be normal. No postural hypotension could be demonstrated. He had no history of cardiac disease. At esophagoscopy, esophagitis and gross reflux were demonstrated. During the patient's stay in hospital three episodes of sinus bradycardia were recorded, all of which were precipitated by lying down. These attacks were terminated by atropine, which reversed the bradycardia of rate 40 to the normal rate of 76. At operation the patient's large sliding and paraesophageal hiatus hernia {Fig. 5) was repaired and there has been no subsequent recurrence of the arrhythmia.
Fig. 3, Case 1. ECG showing normal rate (75 beats per minute).
Discussion
The majority of hiatus hernias produce no s y m p t o m s . V e r y r a r e l y t h e y m a y p r o d u c e p a i n on effort. O c c a s i o n a l l y t h e y m a y p r o d u c e s u b s t e r n a l o r p r e c o r d i a l d i s c o m f o r t w h e n t h e p a t i e n t is b e n d i n g o r l y i n g on t h e left side. I t is p r o b a b l e t h a t m o s t s y m p t o m s a t t r i b u t e d to h i a t u s h e r n i a s are actually due to reflux esophagitis. Resemb l a n c e s m a y b e d u e t o t h e t r a n s m i s s i o n of p a i n impulses from the esophagus over cord segments which are similar to those carrying pain impulses from the heart. Particularly with large hernias which cause displacement of thoracic structures t h e r e m a y b e d y s p n e a or p a l p i t a t i o n s . A s s o c i a t e d spasm of the diaphragm may produce referred p h r e n i c p a i n in t h e l e f t s h o u l d e r region, a n d t h i s may be projected downward into the arm and be associated with palpitation, thus simulating c a r d i a c disease. C h a n g e s in p o s t u r e c a n p r o d u c e effects on heart rate. Thus, on adopting the supine position c a r d i a c o u t p u t i n c r e a s e s a n d h e a r t r a t e will fall. I n f a c t , u s u a l l y t h i s a c c o u n t s o n l y for a s m a l l r e d u c t i o n in b a s a l r a t e , y i e l d i n g a r a t e a few b e a t s below normal value for a short time. However,
American Heart Journal
Fig. 4. Case 2. Chest x-ray showing hiatus hernia trapped within the chest.
t h e r e a r e c a r d i o v a s c u l a r reflexes w h i c h c a n profoundly affect heart rate and can produce s i g n i f i c a n t b r a d y c a r d i a . T h e s e reflexes a r e init i a t e d b y s t i m u l a t i o n of t h e n e r v e s or n e r v e e n d i n g s in t h e v e n t r i c l e s , left a t r i a , a n d e p i c a r d i u m . S t i m u l a t i o n o f r e c e p t o r s l o c a t e d in t h e e p i c a r d i u m is f a v o r e d a s t h e e x p l a n a t i o n o f p r o d u c t i o n of b r a d y c a r d i a in h i a t u s h e r n i a s . B r i e f o c c l u s i o n of t h e o u t f l o w f r o m t h e c a n n u -
31
Marks and Thurston
Fig. 5. Case 3. Barium swallow showing large sliding and paraesophageal hiatus hernia. lated c o r o n a r y sinus in the open-chest anesthetized dog caused a rise in c o r o n a r y venous pressure a n d b r a d y c a r d i a 2 T h e b r a d y c a r d i a was abolished b y i n t r a v e n o u s atropine. This response was abolished b y c u t t i n g the cervical vagi a n d reversibly abolished by cooling t h e m to less t h a n 7 ~ C, Distension of the left a t r i u m with or w i t h o u t c o n c o m i t a n t p u l m o n a r y venous distension has been found to cause b r a d y c a r d i a in a n e s t h e t i z e d dogs. -~B o t h these m e c h a n i s m s are n o t t h o u g h t to b e r e l e v a n t to the m e c h a n i s m of p r o d u c t i o n of b r a d y c a r d i a in h i a t u s hernias. I t has been found t h a t 25 to t00 t~g of a c e t y l s t r o p h a n t h i d i n to the epicardium of the left ventricle of anesthetized and u n a n e s t h e t i z e d dogs caused bradycardia. 3 T h e response developed after an a*cerage latency of 8 seconds a n d lasted up to 12 minutes. Cooling the cervical vagi to 8 to 10 ~ C. or prior application of 1 per cent procaine hydrochloride to the epicardium o f the h e a r t blocked the response. T h e response was therefore a reflex of the sensory receptors being located in the surface layers of the left ventricle. Electrophysiological recordings f r o m simple and multifiber p r e p a r a t i o n s of the
32
right r e c u r r e n t cardiac nerve show t h a t the receptors for this reflex are t h e m e c h a n o r e c e p t o r s whose fibers b e l o n g to the C group. T h i s was confirmed b y Bergel and Makin, 4 who showed t h a t epicardial s t i m u l a t i o n of the left ventricle with nicotine in open-chest anesthetized dogs produced a fall in h e a r t r a t e m e d i a t e d reflexly b y the vagus. T h e e x t r e m e similarity of t h e changes following epicardial s t i m u l a t i o n to those seen in the fainting reaction, with p a r t i c u l a r reference to bradycardia, raises the possibility of a m o r e t h a n fortuitous resemblance. It m u s t be stressed t h a t none of the three p a t i e n t s h a d at a n y t i m e significant h y p o t e n s i o n or a n y of the o t h e r s y m p t o m s of fainting. F u r t h e r m o r e , the persistence of the b r a d y c a r d i a and the f a c t it disappeared on adopting the erect posture save on those occasions during which the hernia r e m a i n e d within the chest radiologically, points to the pressure effect on epicardial receptors as b e i n g the m o s t likely explanation. T h e fact t h a t the b r a d y c a r d i a was abolished by atropine points to its vagal mediation.
Summary T h r e e cases of large mixed sliding and paraes0phageal h i a t u s hernias are described. T h e s e were associated with episodes of sinus bradycardia. T h e b r a d y c a r d i a was abolished by a t r o p i n e pointing to vagal mediation. After surgical repair of the hernia there was no recurrence of the a r r h y t h m i a . T h e s e cases h a v e been considered w o r t h y of r e p o r t since sinus b r a d y c a r d i a has not been recorded specifically in association with hiatus hernias.
REFERENCES 1. Muers, M. F., and Sleight, P.: The reflex cardiovascular depression caused by occlusion of the coronary sinus in the dog, J. Physiol. 221:259, 1970. 2. Edis, A. J, Donald, D. E., and Shepherd, J. T.: Cardiovascular reflexes from stretch of pulmonary vein-atrial junctions in the dog, Circ. Res. 27:1091, 1970. 3. Sleight, P., Lall, A., and Muers, M.: Reflex cardiovascular effects of epicardial stimulation by acetylstrophanthidin in dogs, Circ. Res. 25:705, 1969. 4. Bergel, D. H., and Makin, G. S.: Central and peripheral cardiovascular changes following chemical stimulation of the surface of the dog's heart, Cardiovasc. Res. 1:80, 1967.
January, 1977, Vol. 93, No. 1