72-year-old Mr X was taking his routine walk in the morning when he felt giddy for a minute. He sat down, recovered and continued to walk. He had noticed similar episodes of momentary blurring of vision that occurred nearly once a month for the last couple of months. Mr X attributed it to his advancing age and decided to avoid a heart specialist in Mangalore. A couple of weeks later, he was sitting on a chair reading the newspaper when he lost consciousness and fell down. He regained consciousness within a minute and realised that he had hurt his head. This time around he decided to visit a doctor........
‘Syncope’ or faints is a common problem and occurs in up to 40% of the general population at least once during a lifetime. It may be caused by a benign condition, but it may also be a sign of a serious, life-threatening illness. Syncope refers to momentary loss of consciousness and resultant fall that occurs from a transient decrease in blood supply to the brain. The heart is responsible for maintaining blood supply to all organs of the body including the brain. Intermittent slowing of the heart or a precipitous fall in blood pressure while standing can transiently decrease the blood supply to the brain resulting in loss of consciousness.
It is important to understand that although syncope or faints result in transient loss of consciousness, it is NOT A PROBLEM OF THE BRAIN. It results from a transient interruption of the blood supply to the brain usually secondary to a cardiac or vascular cause.
There are 3 main causes of syncope-
Vasovagal syncope or ‘The common faint’: This is frequently encountered in young children and adolescents and is generally harmless. It is typically preceded by prolonged standing or an emotional outburst and results from a sudden precipitous drop in blood pressure.
Orthostatic Hypotension: This is frequently seen in the elderly especially those on cardiac medications. Trying to stand from a lying down or sitting position results in a drop in blood pressure and lightheadedness or syncope.
Arrhythmic syncope: While the above two commonly encountered causes of syncope are benign and can be easily treated, arrhythmic syncope can be dangerous and recurrent. Arrhythmic syncope results from fluctuations in the heart rate (usually sudden intermittent slowing of the heart rate or episodes of very rapid heart rates) that transiently interrupts the blood supply to the brain.
Whenever a fainting episode is associated with one of the following signs early and detailed evaluation is mandatory to rule out a more sinister cause for the faint:
Faints that occur while sitting or lying down.
Faints that occur while walking or running.
Faints that cause injury (commonly to the head)
Rapid heart beating or chest pain preceding the faint.
Faints that occur in patients with prior heart disease.
Faints in people with a family history of sudden death.
Faints in the elderly.
While the common can be suspected from the patient’s history, it can be easily confirmed by a Head-Up Tilt Test (HUTT) which reproduces the fainting spell under controlled conditions. Arrhythmic syncope is more difficult to diagnose and more often requires continuous recording of the heart rate for 24-48 hrs using a HOLTER machine or sometimes for longer periods of upto 7-14 days using specialized External Loop Recorders (ELR) that are used as a chest wall patch. The electrophysiologist may also perform a diagnostic EP study in certain cases, wherein specialised wires are introduced into the heart to study the intactness and any abnormalities in the heart's conduction system. In a small percentage of people whose diagnosis remains elusive despite the above tests prolonged monitoring of the heart rate for upto 2 years is possible using specialised Implantable Loop Recorders (ILR). Book an appointment in the best heart hospital in Mangalore today to know more.
Drinking plenty of water
Avoid standing for prolonged periods. Keep shaking or moving the legs frequently while standing for prolonged periods.
Some patients may experience a brief period of nausea, sweating, or light-headedness before passing out. It is important to recognize these premonitory symptoms and lie down flat or squat at the earliest sign of giddiness. Avoid standing while giddy.
Perform tilt training exercises.
Avoid sudden standing (especially the elderly). While getting up from bed, sit up for 2-5 minutes, dangling legs, and then stand slowly with support.
The essential aspect of management is to establish the precise cause of the patient's episodes of syncope in order to provide appropriate treatment and advice. Common faints respond to tilt training exercises and certain lifestyle modifications and warrant no further treatment. Arrhythmic syncope on the other hand definitely warrants hospitalization, detailed evaluation and treatment. Based on the rhythm abnormality either a Pacemaker (for slow heart rates) or an ablation or Implantable Cardioverter Defibrillator (for rapid heart rates) may be advised.
Consultant - Cardiac Electrophysiologist
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