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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 2, March/April 2020
AFRICA
65
Does acid reflux precipitate ischaemia in subjects with
acute coronary syndrome?
Sunil K George, Boikhutso Tlou, Somalingum Ponnusamy, Datshana P Naidoo
Abstract
Aim:
It has been postulated that gastro-oesophageal reflux
disease (GORD) may trigger coronary ischaemia through
viscerocardiac reflex vasoconstriction in subjects with ischae-
mic heart disease (IHD). Our aim was to estimate the preva-
lence of GORD in subjects with IHD who present with acute
coronary syndrome (ACS) and to determine whether GORD
may serve as a trigger for ischaemic events.
Methods:
Twenty patients with isolated reflux oesophagitis
and 39 with acute coronary syndrome (ACS with concomi-
tant GORD) were studied. Twenty-two subjects comprising
normal volunteers and those who were admitted for minor
surgical trauma were used as normal controls. All subjects
underwent oesophago-gastroduodenal endoscopy (EGD)
and acid instillation with hydrochloric acid (0.1 M), as well
as nuclear imaging (sestaMIBI) with technetium
99
. Ischaemia
was detected by ST depression using ECG monitoring for one
hour during and immediately after EGD.
Results:
Of the 111 subjects with ACS, 39 (35.1%) had erosive
GORD and comprised the study group. Subjects with ACS
had more incidence of diabetes (
p
=
0.001), hypertension (
p
=
0.002), a history of smoking (
p
=
0.006) and elevated serum
triglyceride levels (
p
=
0.008) compared to the GORD group.
Risk-factor clustering in the form of the metabolic syndrome
was more common in ACS subjects (44 vs 5%;
p
=
0.008). ST
depression was documented in 8/39 (20.5%) patients in the
ACS group and 5/20 (25%) in the GORD group (
p
=
0.958).
Reversible perfusion defects on sestaMIBI scan were seen in
35.6% of the ACS subjects.
Conclusion:
Although GORD is common in subjects with
ACS, we have not been able to show that GORD may serve
as a trigger for ischaemia in these subjects.
Keywords:
reflux oesophagitis, ischaemia, chest pain
Submitted 8/2/19, accepted 12/8/19
Published online
Cardiovasc J Afr
2019;
31
: 65–70
www.cvja.co.zaDOI: 10.5830/CVJA-2019-048
Chest pain is one of the most frequent complaints in the
emergency department and demands careful evaluation in order
to determine the aetiology and institute appropriate care. Of
all the chest pain syndromes, gastro-oesophageal reflux disease
(GORD) is perhaps the most common, with prevalences ranging
from two to 10% in Europe and 7% in America.
1
Significant
co-morbidity in the form of obesity often co-exists, with its
associated complications such as erosive oesophagitis
1-6
that
frequently presents with heartburn and must be differentiated
from cardiac ischaemia or myocardial infarction.
The epidemiology of GORD therefore requires further study
in the ischaemic heart disease (IHD) population, including those
presenting with acute chest pain.
7
We examined the prevalence
of GORD in subjects with acute coronary syndrome (ACS) and
attempted to show whether GORD could precipitate ischaemia
in these subjects.
Methods
Patients admitted to the coronary care unit (CCU) with a
diagnosis of ACS were screened for the study. ACS was defined
according to the criteria of Braunwald.
8
Patients who were stable
and pain free for at least three days were studied. Patients who
were acutely ill or unstable, and those with renal impairment, left
bundle branch block or known peptic ulceration were excluded.
After obtaining informed consent, the subject was examined,
bloods were sampled and the baseline electrocardiograph (ECG)
was recorded. Parameters recorded included weight measured
to the nearest 0.5 kg, and waist and hip circumferences as well
as height according to standard guidelines.
9
Risk factors were
identified and categorised according to the presence/absence of
the metabolic syndrome using the harmonised criteria.
10
For the endoscopic procedure, after an overnight fast, subjects
underwent oesophago-gastroduodenal endoscopy (EGD) and
acid instillation. With the endoscope positioned just proximal
to the esophago-gastric junction, a volume of 60 ml of 0.1 M
hydrochloric acid was administered over five minutes.
11
The acid
concentration was prepared by adding 5 ml of concentrated
acid to 495 ml of deionised water. All EGD procedures were
performed in the gastrointestinal (GI) unit by the author (SG)
using a fibre-optic instrument (Olympus Evis 2000, Tokyo,
Japan). The Los Angeles method was used to classify reflux
oesophagitis (Table 1).
12
During endoscopy, an electrocardiographic Holter recording
was performed and 0.1 M acid was instilled via endoscopy.
The Holter recording was performed for an hour using a
three-channel recorder (Schiller MT101 Baar, Switzerland).
The diagnosis of ischaemia was inferred if at least 1 mm ST
depression was observed during, and/or in the hour after acid
installation. Ventricular arrhythmias were graded according
to Lown’s criteria,
13
i.e. grade 0: no ventricular premature
depolarisations, grade 1:
<
30 ventricular extrasystoles per
Department of Cardiology, Nelson R Mandela School of
Medicine, University of KwaZulu-Natal, Durban, South
Africa
Sunil K George, MD, FCP (SA)
Somalingum Ponnusamy, MB ChB, FCP (SA), Cert Cardiol
(Physicians) (SA)
Datshana P Naidoo, MD, FRCP,
naidood@ukzn.ac.zaDiscipline of Public Health Medicine, School of Nursing
and Public Health, University of KwaZulu-Natal, Durban,
South Africa
Boikhutso Tlou, BSc, PhD