Have you ever experienced a combination of gastrointestinal symptoms, such as acid reflux or heartburn, with cardiac symptoms like palpitations or arrhythmias?
This unusual combination of symptoms is known as Roemheld Syndrome, also called gastrocardiac syndrome. Ludwig Roemheld first observed this connection between gastrointestinal and cardiac symptoms in the early 20th century.
An interesting review recently published on Cureus, the open access medical journal for a new generation of doctors, researchers, and patients, focuses on Roemheld syndrome.
The rare condition links gastrointestinal and cardiac symptoms through the vagus nerve. Despite being a common complaint among primary care patients, the epidemiological link between gastroesophageal reflux disease (GERD) and cardiac arrhythmias is not well understood.
The review presents a clinically diagnosed case of Roemheld syndrome in a patient with a hiatal hernia, whose gastrointestinal and cardiac symptoms were successfully treated with robotic-assisted hernia repair, esophagogastroduodenoscopy (EGD), and LINX magnetic sphincter augmentation.
The patient
The patient in the case study was a 60-year-old male with a history of oesophageal stricture and hiatal hernia who presented with complaints of GERD and related arrhythmias for five years.
The patient did not have a history of cardiovascular disease other than hypertension. Cardiac work-up revealed arrhythmias that were characterised as supraventricular tachycardia with intermittent pre-ventricular contractions (PVC); however, testing was unable to determine a cause for the arrhythmias.
High-resolution manometry showed low pressure in the lower oesophageal sphincter with normal oesophageal motility. Further evaluation included a 96-hour Bravo test and DeMeester score of 31 was recorded, for confirming mild GERD.
Surgeons elected to perform a robotic-assisted hiatal hernia repair, EGD, and magnetic sphincter augmentation. Four months following surgery, the patient denied symptoms of GERD or episodes of palpitation and subsequently weaned off proton pump inhibitors with continual lack of symptoms.
The findings
The review discusses the potential mechanisms that link GERD and cardiac arrhythmias, including autonomic imbalance associated with reflux-induced vagus nerve stimulation or local inflammation of the left atrium triggered by oesophageal reflux.
The anatomical relationship between a herniated fundus and the anterior vagal nerve may also cause direct physical stimulation that increases the risk of dysrhythmia.
The review highlights the need to consider Roemheld Syndrome in patients with anti-arrhythmic resistant supraventricular arrhythmias and a significant history of GERD, especially those who also have a hiatal hernia.
Patients who present with gastrocardiac symptoms such as palpitations, dizziness, or shortness of breath in the presence of GERD symptoms or meal consumption may need to be considered for periodic electrocardiograms to detect the presence of atrial fibrillation (AF), or other types of cardiac arrhythmia.
What does it mean?
The review concludes that Roemheld Syndrome is a unique diagnosis for which the pathophysiology is still yet to be understood.
Awareness of Roemheld Syndrome may help healthcare providers recognise gastrocardiac symptoms in their patients and when possible, use the treatments for gastrointestinal symptoms to prevent a need for anticoagulation or antiarrhythmic treatment for AF control.
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