syncope etc

I am a 30 year old (white male) nursing student, and I REALLY hope you can help me since my doctor has admitted he is at a dead end.

On 9-27-07 when I had a colon and EGD to evaluate diarrhea, and a minor amount of blood in stool.  Proctitis (of a possible autoimmune cause) is all, and I'm better w/o meds.

4 days after the scopes (coincidence??)  I felt a few hard flutters and then near syncope after standing for 15 minutes.

Around 2 months later, it happened again and I just ignored it.  

The saga continues...Starting a couple weeks ago, I began getting weak and nauseated and even started having near syncope even while sitting down.  I have realized that my chronic weakness is almost certainly caused by (or coincides with) my BP being now chronically lower than it ever has been, and that the syncope is due to sudden, sharp drops in my BP.   The syncope has occurred both with and without tachycardia as well as with and without any discernable palps.  

My BP is around 100/55 now and I know that's not "bad" but considering only a year ago I was borderline hypertensive, and the fact that after I do anything to raise it (such as eating) I feel much better, I am very sure that this is the cause of my ill feeling. When my BP is low I also feel an odd "pulsitile clawing" and a certain distinct heaviness in the chest.  When I exercise I'm not really short of breath but my heart feels like it is flexing extremely hard (like it will give up if pushed harder).

Orthastatic testing non revealing, CBC, chem, TSH, cortisol, head CT...Nothing is revealing.

The questions I have...
Why is my BP chronically lower now, why am I having sudden sharp drops? Why, why, why is my pressure gone from hyper to almost hypo?
HOW CAN I KEEP MY BP to at least maintain 120/70 (the thresh-hold to which I feel better), if truly nothing is seriously wrong with me?
I've got a loop recorder on now, but what if I am symptomatic and it doesn't pick anything up, what then?

[Michael J. McWilliams, M.D.]

These are tough, but not uncommon cases.  If you really want an answer, you may need to see a syncope specialist like Blair Grubb at Toledo.  It is likely that you have neurocardiogenic sycnope.  That means your blood pressure drops and your heart rate may or may not increase to compensate for it.  I cannot explain the fluctuations in blood pressure.

You need to eat a high salt, high fluid diet and wear 20-30 lbs pressure stockngs.  If this does not help, there are medications like SSRIs, midodrine, fludrocortisone, pyrdiostigmine that might be able to help.  If there are certain situations that provoke this like prolonged standing, you will have to figure out how to avoid them.

I hope this helps.  Syncope is a tough problem, especially when it is not related to a heart rhythm issue.

[LukeL]

I think this may be  the first time I have hear the Doc reccomend a high salt diet. Also if the loop recorder doesn't show anything with symptoms then it makes the case for a heart problem very low.

[proobot]

So, given that this is common (did you mean common in young people too??),   then how often do you see any serious progression or worsening of symptoms,   and how often do you see spontaneous recoveries or improvements?

Many thanks,,

[kitcurious]

My cardiologist recommended I eat a lot of salt and drink a lot fluid.I believe it is a frequent recommendation under those circumstances

[LukeL]

My comment was a little tounge in cheek. It is just uncommon to have low blood pressure and be reccomended a high salt diet.

[Michael J. McWilliams, M.D.]

Luke's comment is well taken and can actually be a problem when you have a heart failure patient that should avoid salt that has syncope where we recommend salt.

It is hard to say what happens to syncope over time.  Some people grow out of it, rarely it gets worse.  If it is a situational problem, it often gets better with decondtioning -- like seeing blood frequently in medical student that get syncopal at seeing blood.  You can't really predict how it is going to progress/improve.