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Reoccurrences syncope with negative tilt table
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Reoccurrences syncope with negative tilt table

My husband has been having syncopal episodes about 1-2 week with more than 100 stitches to face/body resulting from collapse.  Negative tilt x2, negative CT, negative EEG, has loop recorder showing sinus tach (180's) then drop to 60 prior to collapse.  He gets no warning except tunnel vision and out.  There is no connection to stress it can be just walking to another room in the house.  Sometimes he has confusion after or headache but not usually before.  We have tried Florine's without any change.  Also compression stocking, fluids too.  Please any suggestions prior to him really hurting himself beyond stitches
Tags: syncope
Avatar_dr_m_tn
Dear Joanbolzan,

I’m sorry to hear about your husband’s syncope. Given the injuries he has sustained I agree that it is very important that an effective treatment be identified.

Syncope is a broad term used to define episodes of collapse. A CT brain and EEG are used to rule out stroke and seizure-like activity (i.e. epilepsy) whereas the loop recorder is used to identify disturbances in heart rate or rhythm. Interestingly your husbands loop recorder showed sinus tachycardia with a sudden drop in heart rate to 60 beats per minute prior to collapse. This finding is highly suggestive of ‘neurally mediated syncope’ (also referred to as vasovagal and neurocardiogenic syncope). Neurally mediated syncope describes the triggering of a decrease in heart rate and ‘vasodilation’ (or relaxation) of the bodies blood vessels leading to a drop in blood pressure. When there isn’t enough blood flow to the brain, patients faint. One positive side effect of this is that after collapse, the brain is at the level of the heart making blood flow to the brain easier. Unfortunately for your husband he has sustained significant injuries.

Patients with neurally mediated syncope classically report symptoms immediately prior to their collapse, including nausea, flushing, and sweating. Some identify a trigger such as pain or anxiety. Family members may observe that their loved one becomes suddenly pale before losing consciousness. Patients may have a childhood history of fainting. A positive family history of ‘easy fainting’ can suggest a genetic cause.

Whether your husband requires further testing to confirm the diagnosis is not entirely clear. The history provided in combination with the loop recorder is highly suggestive and could be used to confirm the diagnosis and justify treatment for neurally mediated syncope. A negative tilt-table test is useful in ruling in or ruling out neurally mediated syncope when there is doubt surrounding the patient’s history. However based on your information the history is highly suggestive and supported by the loop recorder.

Other causes of syncope that should be excluded include: other rhythm disturbances (should have been caught by the loop recorder), heart valve problems (ruled out by echocardiogram), pulmonary emboli (clots to the lungs, ruled out by clinical history/exam/CT), medication side effects (especially blood pressure and heart rate lowering medications), and nerve injury secondary to diabetes and other medical conditions. Postural orthostatic tachycardia syndrome [POTS] is being increasingly recognized as a cause of syncope and may be considered a sub-group of neurally mediated syncope.

Given that your husband has had a loop recorder I suspect that you have already seen an electrophysiologist. A loop recorder differs from a Holter monitor in that it is implanted under the skin and left in place for a period of months to years. You mention ‘florine’s’ – I think you’re referring to fludrocortisone which is a steroid commonly used in the treatment of neurally mediated syncope. This works in some cases but some trials have suggested the benefits may be limited in some patients and alternative treatments are therefore required. Other medical treatment options include beta-blockers and midodrine: both should be discussed with your cardiologist. Doctors require updates from their patients if symptoms have not improved following a prescribed medication so I would feel confident that your doctor will want to know if the fludrocortisone has not helped.

In addition to compression stockings I recommend patients keep their fluids up not only with water but sports drinks that contains salts and minerals that help with blood pressure regulation (i.e. 'Gatorade'). Some patients notice an improvement in dizziness after adding 2 x 350ml sports drinks per day. Licorice tablets are also useful and can be bought from your local health store. The trick with compression stockings is that they need to come up to the hip – not just below knee.

I hope that some of this helps. It can take some trial and error but many patients will notice improvements in their dizziness and syncope.

Take care and good luck.
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