Acupuncture therapy rapidly terminates intractable hiccups complicating acute myocardial infarction.

Abstract: Acupuncture is a well-known alternative therapy in practice worldwide. Its dramatic effect on hiccups has been rarely reported. We describe a 77-year-old male who had hiccups after an acute myocardial infarction. Despite aggressive treatment including breath-holding to interrupt the respiratory rhythm, continuous positive airway pressure, and medication with metoclopramine, prochlorperazine, chlorpromazine, haloperidol, mephenesin, diphenylhydantoin, baclofen, and phenobarbital, the hiccups persisted for 7 days. Eventually, the hiccups were rapidly terminated by acupuncture at acupoint GV14 (Da zhui). To the best of our knowledge, this is the first report of acupuncture's reversing intractable hiccups after an acute myocardial infarction. Acupuncture may be considered for patients with hiccups refractory to conventional therapy.

Key Words: acupuncture, acute myocardial infarction, hiccups, treatment

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Hiccups are intermittent, abrupt, involuntary contractions of the diaphragm resulting in sudden inspiration abruptly opposed by closure of the glottis. The diaphragmatic contraction is often unilateral, occurring more often on the left side. (1) Most hiccups occur as brief, self-limited episodes lasting only for a few seconds or minutes but sometimes may last for prolonged periods (>48 hours), interfering with rest, sleep, and eating and causing fatigue, exhaustion, depression, and on occasion, death. (2) In addition to treating underlying disorders, there are numerous methods to quell hiccups. (3) Nevertheless, hiccups may be persistent despite a variety of therapeutic modalities.

In this report, we describe a 77-year-old patient who had intractable hiccups after an acute myocardial infarction (AMI). Ultimately, the hiccups were terminated by direct traditional acupuncture at acupoint GV14 (Da zhui), located at the interspinal space between C7-T1 (Fig. 1).

Case Report

A 77-year-old male was admitted with complaints of sudden-onset chest distress with cold sweats for 4 hours after he had breakfast. There was no history of chest discomfort on exertion, but back soreness was noted on occasion for the previous month. He did not take any medications and had no history of hypertension, hyperlipidemia, or diabetes, but had smoked 3 to 5 cigarettes per day for 30 years and quit 10 years ago. His family history was noncontributory.

This patient had a blood pressure of 110/90 mm Hg, pulse rate of 84 beats/min, respiratory rate of 18 breaths/min, and temperature of 36.6[degrees]C. He was alert but in obvious distress. He had flat jugular veins, regular heart rhythms, and distinct heart sounds without obvious murmurs. The lungs were clear on percussion and auscultation. The remainder of the physical examination was unremarkable. Chest radiography showed clear lung markings with normal distributions and mild tortuosity of the aorta. Electrocardiography, serum cardiac enzyme markers--including creatine kinase (CK), CK-MB fraction, aspartate aminotransferases (AST), and lactate dehydrogenase--and echocardiography were performed. The findings were consistent with the diagnosis of an acute anterior wall myocardial infarction. Thrombolytic therapy with recombinant tissue plasminogen activator (totaling 100 mg within 1 hour) was administered immediately. On the second hospital day, balloon angioplasty was performed on the left anterior descending coronary artery and the first diagonal branch. The cardiac and general conditions were then stable, without specific complaints. The highest levels of CK/CK-MB fraction (3, 196/254 IU/L) and AST (339 IU/L) were noted on the third hospital day, and they returned to normal on the sixth day.

The hiccups developed on the seventh hospital day and progressively increased in severity until the patient could hardly eat or drink. We tried conventional approaches over the next 7 days (such as breath-holding) to interrupt the respiratory rhythm, continuous positive airway pressure, and pharmacotherapies with metoclopramine, prochlorperazine, chlorpromazine, haloperidol, mephenesin, diphenylhydantoin, baclofen, and phenobarbital, to no avail. The refractory hiccups caused him fatigue, insomnia, weight loss, exhaustion, and finally major depression with suicidal thoughts. As a last resort, we tried acupuncture therapy over the GV14 (Da zhui) point located at the interspinal space between C7-T1 (Fig. 1). The needle was inserted and manipulated until a "de-qi" sensation (numbness, tingling or heaviness in the area of the acupoint) occurred. The manipulation was continued for 10 minutes, after the "de-qi" sensation and the hiccups rapidly subsided after a long sigh. The needle was taken out 15 minutes after hiccups ceased. He did not have any recurrence of hiccups at the 1-month follow-up.

Discussion

Hiccups, a ubiquitous phenomenon that affects almost everyone, remains a medical enigma. The pathophysiology of hiccups is thought to be a "respiratory reflex" in origin. The reflex arc is composed of afferent stimulation from the phrenic, vagus, and T6-T12 sympathetic fibers; a hiccup central integrator located either in the cervical cord between C3-C5, the brain stem, or midbrain area; and principal efferent limbs being the phrenic nerves. Hiccups are usually precipitated by direct injury to the reflex arc or an underlying disease inducing injury, irritation, or inflammation to one of the nerves involved in the hiccup reflex arc. (2)

Numerous therapies have been recommended to treat hiccups. (2) They act on the hiccup reflex arc by counteracting the stimulatory impulses, blocking the transmission of nerve impulses, or affecting the underlying causes. Antipsychotic agents such as chlorpromazine and haloperidol have been widely used, but postural hypotension is a common adverse effect. Anticonvulsant agents--diphenylhydantoin, valproic acid, and carbamazepine--also sometimes work. However, bradycardia, heart block, and hypotension are potential risks related to the use of diphenylhydantoin, as well as valproateinduced hepatotoxicity. The dopamine antagonist metoclopramide is effective, but extrapyramidal reactions mandate its cautious use. Moderate success has been reported with sedative-hypnotic agents, for example, phenobarbital, but their reliability is unpredictable. Recently, baclofen, a [gamma]-aminobutyric acid (GABA) derivative with the effect of presynaptic motor neuron inhibition, has been shown to relieve hiccups, but somnolence, fatigue, and nausea are frequent. It can also induce central nervous system suppression with disturbed consciousness in patients with impaired renal function. (4) Several other agents have also been recommended, but most lack evidence of efficacy. Nonpharmacologic therapies such as the Valsalva maneuver, pharyngeal stimulation, phrenic nerve block or crush, or carotid sinus compression can exert their effects through respiratory interruption, counter-irritation, or blockade of vagal or phrenic nerve impulses.

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Persistent hiccups after myocardial infarction have been frequently reported. (5-10) The infarcted areas include the posterior wall, (5,6,8) diaphragmatic portion, (9) lateral, (7) and anterior wall of the left ventricle. (5,7) It has been proposed that stimulation originating from the superficial and deep cardiac plexuses connect to the afferent limb of the hiccup reflex arc causing hiccups. (5) In the past, hiccups after myocardial infarction have been successfully terminated by chlorpromazine, (8) cardioversion, (10) hypnosis, (9) or left phrenic nerve block or crush. (5-7) However, our case is the first using acupuncture to terminate intractable hiccups after AMI. Acupuncture has been successfully shown to influence the course of intractable hiccups (11) and to have a sustained effect in managing the intractable hiccups of malignancy. (12)

Common acupoints for the treatment of hiccups include (1) GV14 (Da zhui) in the interspinal space between C7-T1; (2) PC 6 (Nei guan), 2 cm proximal to the wrist crease between palmaris longus and flexor carpi radialis; (3) CV12 (Zhong wan), midway between the xiphoid and umbilicus; (4) ST 36 (Zu san li), lateral to the tibial tubercle; (5) BL17 (Ge shu), paravertebral points at the level of T6-T7; (6) BL 20 (Pi shu) paravertebral points at the level of T9-T10; (7) BL 21 (Wei shu), paravertebral points at the level of T10-T11; (8) CV 22 (Tian tu), suprasternal notch; and (9) LR 14 (Qi men), 6th intercostal space below the nipple (Fig. 1). (13) In practice, they can be applied individually or in combination. Most of the above-mentioned acupoints are located in or near dermatomes related to the afferent/efferent pathways, secondary synapses, or nuclei involved in the hiccup reflex arc. (13) Many studies have demonstrated that acupuncture can cause multiple biologic responses that occur locally or at a distance, mediated mainly through sensory neurons to many structures within the central nervous system. (14) Locally, it may interrupt the pathways of the reflex arc by changing blood perfusion, activation of the autonomic nervous system, regulation of inflammatory mediators, or altering axonal excitability. It can also influence the hiccup center, with changes in the secretion of neurotransmitters and neurohormones such as endogenous opioids, norepinephrine, serotonin, Substance P, and GABA. (12) The effects of acupuncture can persist for a period of time. This may be partially explained by the fact that acupuncture can induce long-lasting changes in neuronal gene expression leading to persistent neuronal input modulation. (15) The occurrence of adverse events is extremely low. However, potentially life-threatening pneumothorax must be taken into consideration if acupoints located over the anterior or posterior thoracic walls are used. (16)

Conclusion

Intractable hiccups with severe complications may develop after AMI. Acupuncture therapy may provide a simple, cheap, and effective therapeutic modality not only in intractable hiccups complicating AMI but also from other different causes.

Accepted August 11, 2004.

References

1. Launois S, Bizec JL, Whitelaw WA, et al. Hiccup in adults: an overview. Eur Respir J 1993;6:563-575.

2. Friedman NL. Hiccups: a treatment review. Pharmacotherapy 1996;16:986-995.

3. Lewis JH. Hiccups: causes and cures. J Clin Gastroenterol 1985;7:539-552.

4. Chen KS, Bullard MJ, Chien YY, Lee SY. Baclofen toxicity in patients with severely impaired renal function. Ann Pharmacother 1997;31:1315-1320.

5. Swan HR, Simoson LH, Hiccups complicating of acute myocardial infarction. N Engl J Med 1952;247:726-728.

6. Rubun SH, Albright LF, Bornstein PK. Hiccups in coronary thrombosis relieved with phrenic crush. JAMA 1951;146:1418-1420.

7. Ikram H, Orchard R, Read SE. Intractable hiccuping in acute myocardial infarction. Br Med J 1971;2:504.

8. Friedgood CE, Ripstein CB. Chlorpromazine (Thorazine) in the treatment of intractable hiccups. JAMA 1955;157:309-310.

9. Bendersky G, Baren M. Hypnosis in the termination of hiccups unresponsive to conventional treatment. Arch Intern Med 1959;104:417-420.

10. Goldengerg IF, Ochi RP, Almquist A, Benditt DG. Cardioversion for intractable hiccups: a frightening cure. N Engl J Med 1987;316:883.

11. Bondi N, Bettelli A. Treatment of hiccups with acupuncture in anesthetized and conscious subjects. Minerva Med 1981;72:2231-2234.

12. Schiff E, River Y, Oliven A, Odeh M. Acupuncture therapy for persistent hiccups. Am J Med Sci 2002;323:166-168.

13. Haung WS. Acupuncture science, in Huang WS (ed). Acupuncture Therapy for Common Diseases. Taipei, Cheng Chung, 1988, pp 505-512.

14. Pomeranz B. Acupuncture analgesia-basic research, in Stux G, Hammerschlag R (eds). Clinical Acupuncture: Scientific Basis. Heidelberg, Springer, 2001, pp 1-20.

15. Lee JH, Beitz AJ. The distribution of brain-stem and spinal cord nuclei associated with different frequencies of electroacupuncture analgesia. Pain 1993;52:11-28.

16. Anonymous. NIH Consensus Conference: acupuncture. JAMA 1998;280:1518-1524.

RELATED ARTICLE: Key Points

* Stimulation of the superficial and deep cardiac plexuses, which connect to the afferent limb of the hiccup reflex arc, caused by acute anterolateral myocardial infarction, can lead to persistent and intractable hiccups.

* Acupuncture can interrupt the hiccup reflex arc through activation of the autonomic nervous system, change of blood perfusion, inflammatory mediators, and neurotransmitters and neurohormones of the hiccup center.

* Acupuncture over the acupoint GV14 (Da zhui) can be considered as an effective alternative treatment for hiccups refractory to the conventional therapy.

Feng-Cheng Liu, MD, Chiou-An Chen, MD, Sung-Sen Yang, MD, and Shih-Hua Lin, MD

From the Department of Cardiology and Department of Nephrology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China.

Reprint requests to Dr. Shih-Hua Lin, Division of Nephrology, Department of Medicine, Tri-Service General Hospital, N0 325, Section 2, Cheng-Kung Road, Neihu 114, Taipei, Taiwan. E-mail: [e-mail]