718
CASE REPORT Korean Circulation J 2004;34(7):718-720
Cough Syncope Induced by Gastroesophageal Reflux
Kyoung-Suk Rhee, MD
Division of Cardiology, Department of Internal Medicine, Institute of Cardiovascular Research, College of Medicine, Chonbuk National University, Jeonju, Chonbuk, Korea
ABSTRACT
Episodes of loss of consciousness occur in various situations. Although cough syncope has been recognized and described over a hundred years ago, this condition remains a fascinating and incompletely understood clinical entity. In the present case, syncope sometimes occurred during vigorous paroxysms of non-productive coughing that were due to gastroesophageal reflux disease. (Korean Circulation J 2004;34 (7):718-720)
KEY WORDS：Syncope；Cough；Gastroesophageal reflux.
Introduction
Charcot first described cough-induced syncope back in 1876.1) There are a number of different mechanisms reported as causes of cough syncope, such as elevated intrathoracic pressure, elevated cerebrospinal fluid pres- sure, and transient bradyarrhythmias.2-10) We report here on a patient who was found to have gastroesophageal reflux with frequent syncope, and this was due to a tran- sient fall of blood pressure after vigorous paroxysms of coughing. The frequency and strength of the cough be- come reduced markedly, and the syncope disappeared completely after the administration of antacids.
Case
A 56 year-old man was referred for a cardiac consult- ation concerning intermittent syncope following vigorous coughing. The patient had experienced an intermittent
cough while in the supine position for several months prior to his admission. The episodes of syncope occurred after his bouts of coughing. He had no remarkable past medical history. He did not smoke cigarettes or drink any alcohol at all. A routine laboratory examination, chest radiogram, 12 lead-electrocardiogram (ECG), echocard- iographic examination of the heart and treadmill exercise test showed no abnormalities. Holter ambulatory ECG monitoring showed no brady- or tachyarrhythmic episo- des even during the syncope, and an electroencephalo- gram and brain MRI showed no abnormal findings either.
Due to the exacerbation of coughing in the supine posi- tion, he had to sleep in a semi-sitting position for the month prior to admission. Vigorous paroxysms of non- productive coughing were sometimes followed by sy- ncope that lasted about two or three seconds. Arterial blood pressure monitoring was performed to examine the blood pressure during a very short episode of syncope.
After a bout of coughing in the supine position the arterial blood pressure fell markedly from 140/84 to 50/30 mmHg. The patient complained severe giddiness for one or two seconds and then syncope occurred for a moment (Figure 1).
The cough and giddiness were not completely suppre- ssed even with strong antitussives like codeine. An end- oscopic evaluation of the upper GI system revealed the typical findings of reflux esophagitis, since mucosal Received：April 23, 2004
Revision Received：May 25, 2004 Accepted：June 4, 2004
Correspondence：Kyoung-Suk Rhee, MD, Division of Cardiol- ogy, Department of Internal Medicine, Institutes of Cardiovasc- ular Research, College of Medicine, Chonbuk National University, Geuman 2-dong, Jeonju Si Deokjin-gu, Chonbuk 561-712, Korea
Tel：82-63-250-1389, Fax：82-63-250-1680 E-mail：ksee1470@hanafos.com
Kyoung-Suk Rhee
719 redness and several longitudinal erosions covered with
whitish patches were observed in the lower esophagus (Figure 2). After administration of the proton pump inhibitor, Omeprazole in a dose of 20 mg, the coughing
was reduced markedly and the syncope no longer occurred.
During a follow up period of two years, there were no episodes of syncope or severe coughing.
Discussion
Syncope that was caused by severe coughing spells was first described by Charcot1) in 1876. Although this has been recognized and described over a hundred years ago, cough syncope still remains a fascinating and in- completely understood clinical entity. This syndrome, occurring almost exclusively in the obese, stocky, mu- scular middle aged male smoker with chronic bronchitis or emphysema, is characterized by a vigorous paroxysm of non-productive coughing followed by three to five seconds by giddiness and sudden unconsciousness lasting several seconds. A preceding aura, the post-ictal state with incontinence and tongue biting, are well known to be absent in cough syncope.
Coughing in normal subjects and in patients with ch- ronic bronchitis or emphysema causes increased intra- thoracic pressures, from 50 to 150 mmHg, while coughing Figure 2. Endoscopic findings of the lower esophagus
showing mucosal redness and several longitudinal eros- ions covered with whitish inflammatory patches.
Figure 1. Surface ECG and hemodynamic monitoring through the radial artery. Paroxysms of coughing were followed by sudden drop of blood pressure (arrow). A short bout of syncope occurred at that time. The “noise” in the initial portion is due to coughing. ECG: electrocardiogram.
Cough Syncope Induced by Gastroesophageal Reflux
Korean Circulation J 2004;34(7):718-720 720
in patients with cough syncope produces peak pressures of from 200 to 300 mmHg. This increased intrathoracic pressure is transmitted to the intra-abdominal and the intracranial spaces as well. Pressures of this magnitude may act in two ways to cause syncope. First, the cough acts physiologically like a strong Valsalva maneuver, causing decreased venous filling of the atria with a con- sequent decreased blood pressure and stroke volume leading to a decreased cerebral perfusion. Second, the increased intrathoracic, intraabdominal and intracranial pressures produce a “squeezing” of the venous and arterial blood out of the respective cavities, leading again to a decreased cerebral perfusion and hypoxia.2-4) Variable roles may be additively played by a vasovagal reflex, hyperventilation and neuronal depolarization. On the other hand, there have been some reports about cough syncope caused by transient bradyarrhythmias like sinus arrest and complete atrioventricular block.5-8)
The respiratory complications of gastroesophageal re- flux disease have been reported to include hoarseness, wheezing, bronchospasms, stridor, laryngitis, laryngo- spasm and a chronic cough.8) A cough can be the pati- ent’s principal presentation of the gastroesophageal reflux and in several prospective studies, it has accounted for 10-21% of cases with chronic cough.9)10) However, syn- cope as a manifestation of a gastroesophageal reflux induced cough has rarely been described in the liter- ature.11) The patient outlined in this report was moderately obese, but he had no pulmonary pathology and did not smoke. Coughing in the supine position led us to the suspicion of the presence of gastroesophageal reflux disease. Further, an upper gastrointestinal endoscopic exa- mination was performe and the findings revealed a typical pattern of reflux esophagitis. Proton pump inhibitor ad-
ministration was started without doing an ambulatory 24-h pH recording. The frequency and strength of the cough was reduced markedly and the syncope disapp- eared completely after just a few days of the patient taking the medicine. The diagnosis of cough syncope can be made by taking a careful history and by excluding other causes of syncope. As in this case, syncope often resolves after the physician’s optimal management of the underlying cause of the cough.
REFERENCES
1) Charcot JM. Description of “la grande attaque hysterique.”
Progr Med 1879;7:17-20.
2) McIntosh HD, Estes EH, Warren JV. The mechanism of cough syncope. Am Heart J 1956;52:70-82.
3) Skolnick JL, Dines DE. Tussive syncope. Minn Med 1969;
52:1609-13.
4) Sharpey-Schafer EP. The mechanism of syncope after coug- hing. Br Med J 1953;4841:860-3.
5) Choi YS, Kim JJ, Oh BH, Park YB, Seo JD, Lee YW. Cough syncope caused by sinus arrest in a patient with sick sinus syndrome. Pacing Clin Electrophysiol 1989;12:883-6.
6) Hart G, Oldershaw PJ, Cull RE, Humphrey P, Ward D. Sy- ncope caused by cough-induced complete atrioventricular block. Pacing Clin Electrophysiol 1982;5:564-6.
7) Lee D, Beldner S, Pollaro F, Jadonath R, Maccaro P, Goldner B. Cough-induced heart block. Pacing Clin Electrophysiol 1999;22:1270-1.
8) Maceri DR, Zim S. Laryngospasm: an atypical manifestation of severe gastroesophageal reflux disease. Laryngosope 2001;
111:1976-9.
9) Irwin RS, Corrao WM, Pratter MR. Chronic persistent cough in the adult: the spectrum and frequency of causes and suc- cessful outcome of specific therapy. Am Rev Respir Dis 1981;
123:413-7.
10) Irwin RS, Curley FJ, French CL. Chronic cough: the spec- trum and frequency of causes, key components of the diag- nostic evaluation and outcome of specific therapy. Am Rev Respir Dis 1990;141:640-7.
11) Puetz TR, Vakil N. Gastroesophageal reflux-induced cough syncope. Am J Gastroenterol 1995;90:2204-6.
