How to manage a patient with heart failure (HF) who experiences chest pain and hiccups at night, particularly one who typically develops chest pain during dialysis?

Management of Chest Pain and Hiccups in a Dialysis-Dependent Heart Failure Patient

This patient requires immediate evaluation for acute coronary syndrome, as chest pain during dialysis combined with nocturnal symptoms suggests myocardial ischemia, and hiccups can be an atypical presentation of cardiac ischemia that demands urgent ECG and troponin testing. 1, 2

Immediate Assessment and Diagnostic Workup

Obtain an ECG and cardiac troponin immediately to identify acute coronary syndrome, which is a critical precipitating factor for heart failure decompensation and must be treated urgently. 1 The combination of chest pain and hiccups is particularly concerning, as hiccups can represent an atypical manifestation of chronic or acute myocardial ischemia, especially when effort-induced or associated with chest discomfort. 2

Key Clinical Determinations Required

• Assess adequacy of systemic perfusion: Look for cool extremities, altered mental status, decreased urine output, and low pulse volume to identify cardiogenic shock. 1
• Evaluate volume status: Examine jugular venous pressure, pulmonary congestion (lung crackles), peripheral edema, and ascites to determine if fluid overload is present. 1, 3
• Identify precipitating factors: Beyond acute coronary syndrome, assess for severe hypertension, arrhythmias, infections, pulmonary emboli, renal failure worsening, and medication/dietary noncompliance. 1

Essential Diagnostic Tests

• Chest radiograph to assess for pulmonary congestion and rule out alternative causes of dyspnea such as pneumonia. 1
• BNP or NT-proBNP if the contribution of heart failure to current symptoms is uncertain, though interpret in context of renal failure as levels are elevated in dialysis patients. 1, 3
• Echocardiography after stabilization to assess cardiac function, unless hemodynamic instability is present, in which case immediate echocardiography is mandatory. 1

Management of Acute Coronary Syndrome if Present

If ECG shows ST elevation or troponin is significantly elevated, treat the acute coronary syndrome as appropriate to the patient's overall condition and prognosis, as this is the most critical determinant of mortality. 1 This may include urgent cardiac catheterization if the patient is a candidate for revascularization.

Volume Management Strategy

If Fluid Overload is Present

Administer intravenous loop diuretics immediately without delay, starting with a dose that equals or exceeds the patient's chronic oral daily dose if already on diuretics. 1, 3 However, recognize that dialysis patients present unique challenges, as they may have minimal residual renal function and diuretics may be less effective. 4

• Monitor urine output hourly and assess for reduction in dyspnea, lung crackles, and peripheral edema. 1, 3
• If diuresis is inadequate (less than 100 mL/hour over 1-2 hours), intensify the regimen by using higher doses of loop diuretics, adding a second diuretic such as metolazone or spironolactone, or using continuous infusion of loop diuretics. 1
• Consider ultrafiltration during dialysis as a reasonable option for refractory congestion not responding to medical therapy, which may be particularly appropriate in this dialysis-dependent patient. 1, 4

If Severe Fluid Overload Without Hypotension

Add intravenous vasodilators such as nitroglycerin or nitroprusside to diuretics in patients with severely symptomatic fluid overload in the absence of systemic hypotension. 1 Start nitroglycerin at 10 μg/min and double every 10 minutes according to response and tolerability, with dose titration usually limited by hypotension. 1

Management of Hypoperfusion or Cardiogenic Shock

If the patient presents with low blood pressure, cool extremities, confusion, poor urine output, or myocardial ischemia, intravenous inotropic drugs such as dobutamine may be reasonable for documented severe systolic dysfunction with low cardiac output. 1 Start dobutamine at 2.5 μg/kg/min, doubling the dose every 15 minutes according to response, with titration usually limited by tachycardia, arrhythmias, or ischemia. 1

• Invasive hemodynamic monitoring with pulmonary artery catheter can be useful for patients with persistent symptoms despite empiric therapy whose fluid status, perfusion, or vascular resistances are uncertain, or who require parenteral vasoactive agents. 1, 5
• Avoid routine use of inotropes in normotensive patients without evidence of decreased organ perfusion, as this is not recommended. 1

Addressing the Hiccups Specifically

Recognize that hiccups in this context may represent myocardial ischemia rather than a benign symptom, particularly given the association with chest pain and the dialysis setting. 2 If acute coronary syndrome is ruled out and hiccups persist:

• Consider phrenic nerve irritation from pericardial effusion or uremia, which can occur in dialysis patients and may require echocardiography to evaluate. 2
• Optimize dialysis adequacy if uremia is contributing to symptoms.
• Symptomatic treatment with chlorpromazine or metoclopramide may be considered if hiccups are intractable and not related to ischemia, though address the underlying cardiac pathology first.

Optimization of Heart Failure Medications in Dialysis Patients

Continue guideline-directed medical therapy (ACE inhibitors/ARBs, beta-blockers, mineralocorticoid receptor antagonists, SGLT2 inhibitors) unless contraindicated, as these medications improve outcomes even in dialysis patients, though they are often inappropriately discontinued. 3, 4

• Beta-blockers should be continued unless hemodynamic instability requires temporary discontinuation, and can be restarted at low doses after stabilization. 3, 4
• ACE inhibitors/ARBs/ARNIs should be continued with careful monitoring for hyperkalemia, which is common in dialysis patients but should not automatically preclude use. 3, 4
• SGLT2 inhibitors and MRAs have shown benefit in heart failure and can be initiated or continued in dialysis patients with appropriate monitoring. 3, 4

Critical Monitoring Parameters

Monitor continuously: cardiac rhythm, blood pressure (consider arterial line if unstable), oxygen saturation, respiratory rate, and urine output. 1, 5

Daily assessments should include: fluid intake and output, daily weight at the same time each day, vital signs, and clinical signs of perfusion and congestion. 1, 3

Laboratory monitoring: Daily serum electrolytes, urea nitrogen, and creatinine during IV diuretic use or active medication titration, with particular attention to potassium and magnesium in dialysis patients. 1, 3

Common Pitfalls to Avoid

• Do not dismiss hiccups as benign in a cardiac patient with chest pain, as this can be an atypical presentation of myocardial ischemia requiring urgent evaluation. 2
• Do not withhold guideline-directed medical therapy in dialysis patients due to concerns about tolerability, as observational data suggests these medications are underutilized despite potential benefit. 4
• Do not rely solely on diuretics in dialysis-dependent patients with minimal residual renal function; consider ultrafiltration as a primary decongestive strategy. 1, 4
• Do not delay treatment while awaiting diagnostic test results if the patient is in acute distress; begin oxygen, diuretics, and vasodilators as appropriate while simultaneously obtaining ECG and troponin. 1