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Heart Rhythm (Expert Forum)
Please help!
Answered by
Michael J. McWilliams, M.D. - atrial fibrillation, Pacemakers, Defibrillators, Arrhythmias (SVT, VT), PVC/PAC, Ablation
Wilmington Health Associates
Wilmington - NC
Questions in the Heart Rhythm forum cover topics that include heart rhythm issues, arrhythmia, irregular heartbeat, implanted defibrillators, pacemakers, and tachycardia.
Please help!
by dinkerdi, Aug 18, 2008 03:43PM
Sinus brady: avg 48BPM but as low as 35-38 BPM Syncope/near syncope with brady 41-35.
No hypotension noted during sinus brady at any rate.---in fact BP is better with lower HR.
Lab testing= WNL
Tile table=neg. (BP slight hypertensive no hypotension/carotid massage neg)
Persantine Stress test=neg.
Heart Cath= slight CAD circumflex and descending arteries < 30%.
Holter monitor=sinus brady/no SA node dysfunction.
30 day event monitor=sinus brady/no SA node dysfunction.
Continue to have syncope and sinus brady avg 3-6 episodes/month.
Cardiologist believes diagnosis of possbly: neruocardiogenic syndrome---but how can this be considered with neg tilt table with "hypertension" and (never) hypotension with syncope/brady?
Cardiologist next wants to place "internal" cardiac montior---wondering why this would be considered as it's more diagnoistic testing that will show "sinus brady" and doesn't (address) the problem of continued syncope and possible injury related to the syncope.
How can neurocardiogenic syndrome be ruled out?
Why not treat the sinus brady with RX to see if this would help---couldn't trial dose of RX also be considered a diagnostic tool?
Why not a pace maker?? and what is the 2008 AHA guidelines for pacer implantation?
Help I'm getting no where fast while continuing to pass out!!
No hypotension noted during sinus brady at any rate.---in fact BP is better with lower HR.
Lab testing= WNL
Tile table=neg. (BP slight hypertensive no hypotension/carotid massage neg)
Persantine Stress test=neg.
Heart Cath= slight CAD circumflex and descending arteries < 30%.
Holter monitor=sinus brady/no SA node dysfunction.
30 day event monitor=sinus brady/no SA node dysfunction.
Continue to have syncope and sinus brady avg 3-6 episodes/month.
Cardiologist believes diagnosis of possbly: neruocardiogenic syndrome---but how can this be considered with neg tilt table with "hypertension" and (never) hypotension with syncope/brady?
Cardiologist next wants to place "internal" cardiac montior---wondering why this would be considered as it's more diagnoistic testing that will show "sinus brady" and doesn't (address) the problem of continued syncope and possible injury related to the syncope.
How can neurocardiogenic syndrome be ruled out?
Why not treat the sinus brady with RX to see if this would help---couldn't trial dose of RX also be considered a diagnostic tool?
Why not a pace maker?? and what is the 2008 AHA guidelines for pacer implantation?
Help I'm getting no where fast while continuing to pass out!!
Doctor's Answer
by Michael J. McWilliams, M.D., Aug 18, 2008 09:59PM
, Aug 18, 2008 09:59PM
It sounds like neurocardiogenic syncope.
Tilt tables are sometimes helpful if positive but not always helpful if negative. It is not a very good test.
If you had a syncope while you were wearing the 30 day monitor, an implantable monitor is not helpful. They are used if syncope cannot be captured on monitor because it is infrequent. If you have 6-8 per month, you should be able to capture an event with a monitor.
Neurocardiogenic syncope is a rule out diagnosis -- it cannot be ruled out with a test. It is what is left if all other tests are negative.
If you didn't have symptoms with the sinus bradycardia, it isn't the sinus bradycardia. There aren't great medications to treat sinus brady without other side effects.
Pacemakers are a last resort once it is proven that the syncope is related to bradycardia, even if it is a bradycardic response during neurocardiogenic syncope. Pacemakers are shown to increase the time until syncope to give you time to sit but aren't always as good at preventing syncope. I have seen a few people that have been helped tremendously by pacemakers but they had a bradycardic response causing syncope. It doesn't sound like that is proven yet.
ACC guidelines are long
http://content.onlinejacc.org/cgi/content/full/j.jacc.2008.02.032
summary is below.
Recommendations for Permanent Pacing in Hypersensitive Carotid Sinus Syndrome and Neurocardiogenic Syncope
Class I
1 Permanent pacing is indicated for recurrent syncope caused by spontaneously occurring carotid sinus stimulation and carotid sinus pressure that induces ventricular asystole of more than 3 seconds. (Level of Evidence: C) (142,152)
Class IIa
1 Permanent pacing is reasonable for syncope without clear, provocative events and with a hypersensitive cardioinhibitory response of 3 seconds or longer. (Level of Evidence: C) (142)
Class IIb
1 Permanent pacing may be considered for significantly symptomatic neurocardiogenic syncope associated with bradycardia documented spontaneously or at the time of tilt-table testing. (Level of Evidence: B) (147,148,150,153)
Class III
1 Permanent pacing is not indicated for a hypersensitive cardioinhibitory response to carotid sinus stimulation without symptoms or with vague symptoms. (Level of Evidence: C)
2 Permanent pacing is not indicated for situational vasovagal syncope in which avoidance behavior is effective and preferred. (Level of Evidence: C)
Tilt tables are sometimes helpful if positive but not always helpful if negative. It is not a very good test.
If you had a syncope while you were wearing the 30 day monitor, an implantable monitor is not helpful. They are used if syncope cannot be captured on monitor because it is infrequent. If you have 6-8 per month, you should be able to capture an event with a monitor.
Neurocardiogenic syncope is a rule out diagnosis -- it cannot be ruled out with a test. It is what is left if all other tests are negative.
If you didn't have symptoms with the sinus bradycardia, it isn't the sinus bradycardia. There aren't great medications to treat sinus brady without other side effects.
Pacemakers are a last resort once it is proven that the syncope is related to bradycardia, even if it is a bradycardic response during neurocardiogenic syncope. Pacemakers are shown to increase the time until syncope to give you time to sit but aren't always as good at preventing syncope. I have seen a few people that have been helped tremendously by pacemakers but they had a bradycardic response causing syncope. It doesn't sound like that is proven yet.
ACC guidelines are long
http://content.onlinejacc.org/cgi/content/full/j.jacc.2008.02.032
summary is below.
Recommendations for Permanent Pacing in Hypersensitive Carotid Sinus Syndrome and Neurocardiogenic Syncope
Class I
1 Permanent pacing is indicated for recurrent syncope caused by spontaneously occurring carotid sinus stimulation and carotid sinus pressure that induces ventricular asystole of more than 3 seconds. (Level of Evidence: C) (142,152)
Class IIa
1 Permanent pacing is reasonable for syncope without clear, provocative events and with a hypersensitive cardioinhibitory response of 3 seconds or longer. (Level of Evidence: C) (142)
Class IIb
1 Permanent pacing may be considered for significantly symptomatic neurocardiogenic syncope associated with bradycardia documented spontaneously or at the time of tilt-table testing. (Level of Evidence: B) (147,148,150,153)
Class III
1 Permanent pacing is not indicated for a hypersensitive cardioinhibitory response to carotid sinus stimulation without symptoms or with vague symptoms. (Level of Evidence: C)
2 Permanent pacing is not indicated for situational vasovagal syncope in which avoidance behavior is effective and preferred. (Level of Evidence: C)
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While wearing the holter monitor I had 2 "events" of syncope episodes with a HR 40-43,
While wearing the 30 day event monitor I had 3 "events" of near syncope with the lowest HR of the 3 "events' being 41.
First became aware of issue was when I awoke at 1AM with mild SOB and dizziness--took my pulse and was 40-41...eventually went to ER. continued dizziness and mild SOB with HR on monitor as low as 35, Lots of lab tests all norm. EKG=sinus brady.
I was sent home from ER and referred to cardiologist who did all the tests I described without coming to any conclusion yet---other than wanting to place the internal monitor...
I also have history of rheumatic fever; with mild regurg of mitral/tricuspid valve per echo approx 2 years ago.
I'm exhausted, I mean really exhausted.
I'm tired of the "dizzies" and having to either pick myself up off the floor or put myself down onto the floor to avoid crashing to the floor. It's scary to drive--not knowing if I'll get the warning of being dizzy prior to passing out or not.
Medication doesn't sound like a good option...? But what are the options?
Pacemaker IS very much the last resort--- and could it possibly make it worse?
What next?
More testing, if so what test?
While wearing the holter monitor I had 2 "events" of syncope episodes with a HR 40-43,
While wearing the 30 day event monitor I had 3 "events" of near syncope with the lowest HR of the 3 "events' being 41.
First became aware of issue was when I awoke at 1AM with mild SOB and dizziness--took my pulse and was 40-41...eventually went to ER. continued dizziness and mild SOB with HR on monitor as low as 35, Lots of lab tests all norm. EKG=sinus brady.
I was sent home from ER and referred to cardiologist who did all the tests I described without coming to any conclusion yet---other than wanting to place the internal monitor...
I also have history of rheumatic fever; with mild regurg of mitral/tricuspid valve per echo approx 2 years ago.
I'm exhausted, I mean really exhausted.
I'm tired of the "dizzies" and having to either pick myself up off the floor or put myself down onto the floor to avoid crashing to the floor. It's scary to drive--not knowing if I'll get the warning of being dizzy prior to passing out or not.
Medication doesn't sound like a good option...? But what are the options?
Pacemaker IS very much the last resort--- and could it possibly make it worse?
What next?
More testing, if so what test?