Dr. Deepak Padmanabhan
Have you ever come across someone who experienced fainting and sought medical consultation and treatment from a neurologist? If yes, it is probably because of the common belief that fainting happens due to a neurological cause similar to seizures. However, this can be primarily cardiac in nature.
Syncope(medical term for faints) is the transient loss of Consciousness (TLoc) with spontaneous recovery which if accurately diagnosed and treated by the correct medical expert i.e. a cardiac electrophysiologist, can be managed very well. There is a high incidence of health service use associated with syncope, including 740,000 annual emergency department visits and 460,000 hospital admissions in the United States. Hospital costs associated with the inpatient evaluation of syncope exceed $2.4 billion per year in the United States.
Common Faints, also known as vaso-vagal syncope, occurs when there is a temporary drop in the amount of blood that flows to the brain due hyperactivity of normal compensatory reflexes of the heart. It frequently occurs when in the standing position and recovers within 10-15s after falling down. The fall may cause injuries although the episode itself is benign and self limiting. It is commonly seen in the middle aged population, predominantly females between 20-40 years of age but can occur at any age.
Use of a head up tilt test (HUTT) is a good way to confirm the diagnosis , although the history of the episode remains the most important point aiding the suspicion of this condition. Hydration, use of stockings, specialised counterpressure manoeuvres and very rarely medications is the mainstay of therapy in these patients . Driving remains prohibited for these patients for at least 3 months after these episodes.
The reason why evaluation of these patients is important is because faints can be the presenting feature of more lethal problems. The heart beats at the rate of 50 to 100 beats per minute and in a sequential manner from the upper chamber to the lower chamber. Any disturbance in either the rate or the sequence is called cardiac arrhythmia. More than 10% of people who experience loss of consciousness could be suffering from arrhythmia either primarily or as a secondary phenomenon to an underlying cardiac condition.
Slow heart rate with abnormal sequences leading to faints is episodic , gradually progressive but irreversible. It needs continuous cardiac monitoring for its diagnosis and may need a pacemaker for its treatment.The type and kind of pacemaker is usually subject to evaluation made by an electrophysiologist.
Increased heart rate with abnormal sequences leading to faints is called sudden cardiac arrest. The first episode by itself can cause fatalities. The worry remains that they may not survive to reach the hospital since blood flow to major organs is cut off almost immediately and starts leading to irreversible organ dysfunction within minutes ; In such circumstances , it is critical that the person next to them recognises the signs of such a faint and is able to administer resuscitation to the patient maintaining blood flow to the brain and heart.
These signs include heavy breathing , lack of normal responsiveness, and absence of a pulse. CPR is an emergency procedure that combines chest compressions to manually restore blood circulation and defibrillation to restore rhythm. There are standard courses for citizens to participate in to learn this where training to recognise these events, call for help and manage the patient till help arrives can be provided. Housing societies and companies should have regular sessions for CPR training for their residents and employees along with procurement of defibrillators for such emergencies.
More the number of people trained to do resuscitation, more the chance that there is a trained person in the vicinity of the patient who faints; a so called ‘Herd Immunity against sudden cardiac arrest’.
Once in the hospital, these patients need specialised cardiac electrophysiology testing and management by mapping and defusing short circuits in the heart supported by implanting cardiac defibrillators to protect against repeat episodes. These are complex diagnostic and therapeutic procedures done at specialist tertiary care centers by trained cardiac electrophysiologists.
The ‘faint’ therefore can be a benign episode or a fatal one. There is a need therefore to get every episode evaluated for an cardiac electrophysiologic cause in order to ensure optimal management is provided to the patient. It is important to remember that syncope or fainting can be the first symptom of an underlying serious cardiac problem and if unrecognized can potentially lead to sudden cardiac arrest. Hence, while it is important to consult the correct medical expert, it is equally crucial to report fainting in the first instance.
Costs of post-arrest care for individuals following hospital discharge can be approximately $42,000 for 30 days of rehabilitation and approximately $100,000 for 365 days of long-term facility care. Each patient utilized resources averaging $19,000 during the first year following an arrest. One estimate places the total cost of out-of-hospital cardiac arrest in the United States at $33 billion/y, and this study suggests that 17% of that total figure is attributable to index hospitalization post cardiac arrest.
Although targeted cost containment for post arrest interventions may reduce the finance burden, the potential economic impact of funding research into prediction and prevention of cardiac arrest offers a greater potential societal benefit, both economically and clinically.
Deepak Padmanabhan is a Consultant Electrophysiologist at Sri Jayadeva Institute of Cardiac Sciences and at the Narayana Institute of Cardiac Studies and is a cardiac researcher from Bengaluru. Views expressed are personal and do not reflect the official position or policy of the Financial Express Online.