Scott Webb (Host): Many of us have fainted or experienced syncope in our lifetime. And though most of the time the causes of syncope are benign, syncope related to heart conditions must be addressed by a medical provider. And I'm joined again today by Dr. Manoj Duggal. He's a Board Certified Cardiologist specializing in cardiac electrophysiology, practicing at Franciscan Health, and he's here today to discuss some of the benign and more serious causes of syncope and how syncope is diagnosed and treated.

This is the Franciscan Health Doc Pod. I'm Scott Webb. Doctor, it's nice to have you back again. Today we're going to talk about syncope and just want to get a sense from you what's happening when a person faints or experiences syncope, and who's most likely to experience that.

Manoj Duggal, MD: I want to right off the bat, differentiate between loss of consciousness and syncope. So loss of consciousness is when somebody loses consciousness, whereas syncope has added determinants, which is somebody loses consciousness, and along with that, they lose their postural tone. And the third component is they have a spontaneous recovery without intervention. So, let me give you an example. When somebody loses consciousness and they're diabetic and they're hypoglycemic, their blood sugars are low, they lost consciousness, but somebody has to intervene to correct their sugars so they get better. Whereas syncope is person will lose consciousness and they will recover spontaneously.

Host: Yeah, so I'm guessing there must be some less serious causes of syncope, some more serious causes of syncope, ones that require medical intervention. So take us through that. Like when or how do we know that it's something more serious?

Manoj Duggal, MD: When somebody has a syncope, the end, what cascade starts it but results in a, a reduced perfusion to your brain. So in other words, there is not enough generation of blood pressure and you lose consciousness.

Host: Okay.

Manoj Duggal, MD: And syncope can happen in all age groups. Generally, younger patients are more benign, whereas we get older have a heart condition, in, in other words, prognosis is much worse when you have heart conditions, you're older.

Host: Okay.

Manoj Duggal, MD: So now you know, you may have seen people go to a restaurant. They say, Hey, you know what, 20 minute wait. You can go to the bar. Somebody goes to the bar, have a drink, and next thing you know, they're on the floor.

And by the time everybody rushes in to help them, they have recovered. So that is more of a reflex mediated syncope. So like somebody goes to the ER and they start an IV and they pass out. So, that's a situational syncope where people have something happen to them and they pass out. You may also see people who have a bout of coughing and they pass out and then the coughing stops.

They fall down or sit down and, that loss of consciousness syncope recovers. So those are generally benign conditions.

Host: Yeah.

Manoj Duggal, MD: Then there are other group of patients where they take certain medications and their blood pressure drops when they stand up, which could be related to medications or just in general loss of blood volume.

Somebody's anemic have very low blood counts and some conditions like Parkinson's, they have what we call as a autonomic dysfunction; when they standup, their blood pressure drops and they pass out, they fall, and as soon as they fall. When you are supine and you in a flat on surface, your blood pressure gets better. Brain starts getting blood, and you regain consciousness.

Host: Right.

Manoj Duggal, MD: So those are generally in more of a benign conditions. But of course when you have that, you can get hurt, right? I mean, you can hit your head, you can bleed. So you can have a bodily injury and these may come back, but they don't generally portray a bad prognosis in the long run.

And now focusing on to conditions which are serious. So for example, if somebody has a very rapid heartbeat, which could come from either upper part of the heart, the atrium or the bottom part of the heart, called ventricle. So when the heart is beating very rapidly, heart is a pump, so it has to fill up blood before it pumps out.

When the heart is beating so rapidly, it doesn't have enough time to fill in blood. That will reduce your blood pressure and you can pass out and eventually some of these reasons will stop and people regain consciousness. So related to heart rate, if you have very slow heart rate, so for example, like we discussed in our last podcast, with very slow heart rate, not enough generation of blood pressure or not enough beats to generate blood pressure, you pass out. So these arrhythmias or rhythm issues, slow or rapid heartbeat, they can be serious depending on other factors associated with it. And then there is a, another condition where there's a structural abnormality. For example, there's a valve which connects the main pumping chamber of the heart called left ventricle and rest of the body called aortic valve. In some people that valve can get very narrow as generally as they grow older. Calcification of the valve, so the valve doesn't open even though heart is trying to pump. But there's no generation of blood pressure and people can pass out. Those can be very serious and they can portray life threatening conditions.

And so is like you have obstruction of blood flow for any reason, or you have a pump, which is the heart, which is weak. So those are the conditions in general, which can cause people to have loss of consciousness. And then there are group of patients where we do every test, we don't find anything abnormal. So in other words, unknown cause of syncope, right? Syncope is a puzzle, right?

Host: Right.

Manoj Duggal, MD: A, we are trying to find out the cause for it, and B, which is also very important, is to say, what is the prognosis of this person who has passed out? Is it good? In other words, is their life expectancy going to be affected because of this?

So that is really the key, is to focus on the cause and also try to find out if their prognosis is still good.

Host: Just thinking about this, as you say, if it's somebody maybe younger, it's probably benign. It could be arrhythmias, too slow, too fast. Blood pressure may be involved. It's a lot to lot to think about, and it's really good that we have experts. So I'm assuming then on the more serious cases, the arrhythmias, the, you know, heart related syncope, I'm assuming you do some cardiac tests. So, what are those tests, as you say, you're trying to get to the root cause, like what's causing the syncope. So what kind of information or details do those tests provide?

Manoj Duggal, MD: Right. So when I see a patient who comes to see me in the office or in the hospital, they have passed out. So the history becomes very important. Hey, what were you doing when that happened? And I have to say, Hey, somebody was bleeding. I saw blood, I passed out. So generally portrays a less serious condition.

But if a younger patient passes out and I ask them, Hey, is there any family history? Yeah, I had an uncle who died at age 30, suddenly died. Well, that tells me, Hey, this could be a very serious condition. So history becomes very important. And the next thing is an examination. Our examination is looking for heart murmurs.

Their blood pressure. If they have a heart murmur, that kind of tells me, Hey, this could be a much serious condition. So once those two things have been kind of probed into the history and the physical exam; the next thing, most of the doctors, we will do an EKG, which is an electrocardiogram, and that gives a snapshot what your heartbeats are doing.

That will give us a clue if you have a tendency to have a slow heart rate and then the next thing which we generally order when we suspect a serious condition is an echocardiogram, which is an ultrasound of the heart where a technician would put jelly on your chest and look at your heart valves, heart muscle to kind of figure out, Hey, is there a problem with the valves?

Is there a problem with the heart muscle? So those are the kind of conditions which will result in these testing and physical exam and sometimes we do all these tests and we don't have any answers. And then we may give people a monitoring device like, you know, you, I'm sure you've heard of Holter monitors.

So now we have patches. You basically give a patient a patch, which could be for 30 days and that can give us clues or if somebody passes out during that period of time and we see, oh, well your heartbeat was too fast or too slow. So that gives us clues, hey, this is the potential cause for it. And then of course, depending on what it is, we can offer treatment.

 And some people have very rare episodes of syncope when they say rare, once or twice a year, even less than that. Then there are implantable monitoring devices, which the batteries last for three years, so we can correlate their symptoms to their heart rhythm. So kind of exclude, is it heart related or is something else? So those are the kind of brief overview of what workup we would do before deciding, hey the cause, and to also kind of pinpoint what is the prognosis of that person.

Host: Right. Yeah. So as you say, a patient history, a battery of tests available. Maybe sometimes the cases are easy, if you will. Sometimes a little more complicated, as you say, might be wearing a monitor for a while, that kind of thing. Just want to finish up today and just talk generally about treating syncope.

You've given us a sense that it could be a variety of reasons, a variety of causes for the syncope, but in general, if it's related to the heart, what are the treatment options?

Manoj Duggal, MD: So let me focus on the benign conditions like situational syncope, blood. So you basically, when you have that, you have tried to avoid those situations and if somebody passes out, the bystanders I would say is, Hey, lay them flat. Make sure they don't have bodily injury and raise their leg. That will help their get their blood pressure better.

So that's kind of clues, hey, you know, this excessive alcohol, excessive caffeine, which makes you lose blood volume so you have to avoid those situations. Now if you pass out and you have a heart condition, you got to go see your doctor, right away because heart condition, like somebody has suffered a heart attack, now you passed out.

That is a very serious condition. So I think the key is being vigilant of what your heart conditions are and about family history and providing that history to your healthcare provider will kind of have them go into the more details and say, Hey, this is serious, this is not serious. 

And if you have conditions like, you start a medication for blood pressure, for example, and you pass out, then you got to tell your doctor, because some of the medicines will decrease your blood pressure when you stand up. That's called orthostatic hypotension. So adjustment of medications, lifestyle changes, and of course if you have a heart condition, make sure that your physician is made aware right away.

Host: Yeah. Yeah, that's perfect. As you say, like if, you know, like, my dad passes out when he sees blood. Right. So in terms of patient history, what were you doing before you passed out? Well, I saw blood. Okay. Well that's an easy one. But some of these other things, especially related to the heart, especially as you're saying, if someone's already had a heart attack or they're on blood pressure medications, those are all good reasons to speak with our providers. Get their assistance, perhaps you or someone else at Franciscan Health. So, thank you so much.

Manoj Duggal, MD: Great. It was a pleasure.

Host: And for more information, visit franciscanhealth.org/heartcare.

And if you found this podcast helpful, please share it on your social channels, and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.