Sunday, September 18, 2011

Near Syncope Question from Sally

Hello Docs,

I am a female, 49 years old. 5’6”, 150 lbs. I am in good health and exercise regularly. I take Imitrex as needed.

This is something that I have been dealing with for most of my adult life. Occasionally my heart will race. It will start to beat very fast, my vision will dim but not to the point of blacking out though at times I think I will, and all of a sudden I will feel very week. This will sometimes happen after I stand up from bending over to pick something up or if, for example, I sniff suddenly to ward off a runny nose in allergy season. There are also times where I will wake up in the middle of the night with my heart racing.

This has never happened when I do any cardio activity.

What I usually do is sit, if I have been standing, or lie down if possible, then I hold my breath. It seems to work after a few tries. My heart will speed up just a little bit more and then one big heart beat and a pause. Then all is back to normal and I feel fine.

So here is my question – what the hell is it? Is there a test I should take or is this just normal and I live with it?

Thank you in advance for your input and advice.


Dear Sally, 

A few questions before we post your response...

What kind of studies have you had? Holter monitor? Cardiac stress test? An 'event monitor'? Have you seen a cardiologist? Have you ever passed out?


Dear Doc1, 
I have never passed out. I have never been to a cardiologist

When I asked my Doc about this, years ago, he didn’t seem very worried. Said something about Mitral valve prolapse and that I didn’t need to worry. If I wanted tests he would order them. Since he was not worried I was not either.

This only happens to me a few times a year.  I find it more annoying than alarming, but I do wonder if it something I should take more seriously.
Thank you,

Doc1 here. I spoke with my colleagues on the blog about your case and will start with my thoughts. I know they have some specific ideas in addition to mine...

I really would want you to get set up with a holter monitor or event monitor. The possibility that you could have SVT or PSVT is first and foremost on my mind. Impossible to diagnose by history alone, you need to get it on an EKG or a monitor strip and a Holter or Event Monitor might be the only way to do this in your case. 

As you can see from this link to a very good Mayo Clinic bit on tachydardia (rapid heart rate), symptoms such as you describe are the result of most of the tachy-dysrhythmias. 

And then there's this, a quote from the same article...

Stopping a fast heart rate
A fast heartbeat may correct itself, and you may be able to slow your heart rate using simple physical movements. However, you may need medication or other medical treatment to slow down your heartbeat. Ways to slow your heartbeat include:
  • Vagal maneuvers. Your doctor may ask you to perform an action, called a vagal maneuver, during an episode of a fast heartbeat. Vagal maneuvers affect the vagus nerve, which helps regulate your heartbeat. The maneuvers include coughing, bearing down as if you're having a bowel movement, and putting an icepack on your face.
The particularly interesting thing in your case is that a form of vagal maneuver seems to sometimes initiate AND abort your symptoms. I think a visit with a cardiologist is in order. If you have Mitral Valve Prolapse then an echocardiogram will tell us and the cardiologsit can then make a decision about whether to pursue monitoring to detect a possible SVT or PSVT problem. I'm going to let my colleagues in at this point.
Be Well


DOC2 said...
DOC2 here. The other interesting thing is that your trigger seems to come from a change in posture. In other words, you bend down and then stand. Sniffing as a trigger is interesting as well. You have what seems to be a "dysautonomia" or a disorder that causes you to have an excessive response to this postural change. It is normal to have an increase in heart rate due to (usually) a low blood pressure that follows the straightening of the body from a bent or stooped position to a standing position. The normal response is that the elevated heart rate happens until the blood pressure equilibrates enough to perfuse the brain and then its rate comes back down to normal. It sounds to me that you have POTS (postural tachycardia syndrome). This is a WIDE topic that covers a range of symptoms and signs. Sometimes it is exhibited by an accelerated heart rate and a change in blood pressure, sometimes not. Sometimes it causes dizziness, sometimes not. Because it also encompasses an abnormal response in the tone of the blood vessels (which help control blood pressure), my thought is that your propensity to have migraines and the symptoms that you have described above are closely linked . If you came into my office, here's what I would do. First, a simple EKG. Would probably be normal, but possibly not. If not, I would send you to a cardiologist. If normal, I would recommend that you have a Holter monitor placed (which is an EKG that you wear around while you do your daily activities). If you're symptomatic around your period, I would try to time it about the same time (assuming that you may be still having a menstrual cycle) or ask you to consider mimicking the events that seem to cause the problem to see if it can be caught. The Event monitor is a Holter that records on a continuous loop and you basically hit a button to tell the monitor that you are having symptoms so that it will save that moment. A tilt-table test might be in order as well. This can help check for the postural problems that I outlined above. You may be able to capture the cause with this as well. The odd part to me is what DOC1 has described above, and that is that you also have a pretty typical pattern to EXTINGUISH a supraventricular tachycardia (SVT or PSVT). This would not be necessarily the rhythm you would have it were JUST a postural tachycardia syndrome. So, you might have TWO things going on here. Is mitral valve prolapse a possible player here? Sure it can be. Are there treatments available out there to aid in the event that you have some kind of autonomic problem? Sure. Do they work? ... sometimes. Should you get it looked at? I would. If symptoms persist or worsen over time, then you might put yourself at risk. You don't have much control over yourself after you pass out. That's my advice, and i don't think that you could ever go wrong investigating this further. Will you yield any helpful results? Sometimes not. I hope this makes sense. If I need to clarify, shoot me a message back.


1 comment:

Anonymous said...

I might add that in the mean time, until you have this worked up further, you might make an effort to remain well hydrated as it sounds that orthostatics may be playing at least a minor role in this given the positional triggers.