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Stress-related Syncope Patient Case Review

A patient case was posted in October 2019 to the Healthcasts Cardiology peer-to-peer community. Nearly 35 unique opinions were contributed. The following is a synopsis of their consensus prevention and management recommendations.


A 59-year-old male patient is a college football coach who collapsed on the sidelines and was diagnosed with a ventricular arrhythmia which self-resolved by the time he had gotten to the ER. His 24-hour Holter monitor demonstrated decreased beat-to-beat variability over 24 hours. How might his sympathetic and parasympathetic nervous systems be contributing to his arrhythmogenesis? What precautions would be helpful in preventing further occurrences?


HEALTHCASTS COMMUNITY RESPONSE

Provided diagnosis:    Stress-related syncope

Total respondents:      34

Case assessed:          November 2019

ASSESSING SYMPATHETIC AND PARASYMPATHETIC NERVOUS SYSTEM CONTRIBUTIONS

Consensus opinions concluded:

If there is low heart rate variability, there is a dominance of the sympathetic nervous system. This is typically associated with stress, inflammation and development of coronary artery disease and hypertension. If the patient were in a high androgenic tone or activation of the sympathetic nervous system, this could provoke a ventricular arrythmia in an abnormally structured heart.

If there is high heart rate variability, there is a dominance of the parasympathetic response. This is typically associated with lesser morbidity. There could be parasympathetic stimulation, which may contribute to vasovagal syncope. Dominance of the parasympathetic nervous system would increase the need for an anti-arrhythmic agent.

DIAGNOSES

The diagnosis provided by the case contributor was stress-related syncope. Differential diagnoses submitted by the community included low heart rate variability, pericardial disease with effusion, arrhythmia, vasovagal syncope and hypertrophic cardiomyopathy.

EVALUATION & PRECAUTIONS

The most common opinion was that this patient should reduce stress and strongly consider leaving his job. However, a full cardiac evaluation was deemed necessary to fully assess the patient, including EKG, echocardiogram, cardiac catheterization, coronary angiography and an electrophysiology lab consult. Important adjunctive recommendations to the patient are to maintain proper hydration, exercise regularly, get proper sleep and avoid standing up too quickly. Some felt it would also be prudent to restrict the patient from driving for six months.

PREVENTION

Some respondents would recommend prescribing a beta blocker to reduce stress, anxiety and excess vagal stimulation, all of which may exacerbate the patient’s arrhythmia. Over a third of the respondents concluded that implantable defibrillator therapy is likely a good option for this patient to continually monitor and restore normal heart rate, preventing further occurrences.

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