A 70-year-old female, after eating a fatty, spicy meal, wakes up at 3 a.m. with substernal chest pain associated with burning in the chest that was relieved on sitting up and also on taking antacids. Her pertinent negatives are the absence of exertional chest pain, dyspnea, and lower extremity edema. She started taking a new medication, Procardia, which can cause relaxation of the lower esophageal sphincter, leading to acid reflux and esophageal spasm. Her differential diagnosis includes atypical chest pain, cardiac ischemia, or gastric acid reflux. Her cardiac enzymes, EKG, and echocardiogram are normal.

The combination of high-fat content meal, and pain relieved when sitting up and after taking an antacid all indicate acute onset or exacerbation of GERD. In addition, the adverse effect of Procardia may have precipitated the episode.

The advanced practice provider provides teaching about the need to avoid foods with a high-fat content and that are spicy. The patient should also sit upright for at least 60  minutes after eating, avoid eating for several hours before going to sleep, and limit the intake of alcohol and caffeine. Should the symptoms continue, the cardiologist should be notified of the patient’s adverse effect to determine if a medication change would be indicated.