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Showcasing Best Practice In Syncope
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Young patients with syncope
Professor Richard Sutton and Dr Phang Boon Lim
Hammersmith Hospital, Syncope Unit, Imperial College Healthcare NHS Trust, UK
Female, 16 years old, presented frequent syncope. Tilt-testing: vasovagal (VVS) tendency, excessive heartrate. Diagnoses: VVS, psychogenic pseudo-syncope, postural orthostatic tachycardia. Ivabradine and close supportive follow-up completely resolved symptoms. Presentation of syncope is never simple, requiring diligence in history-taking and analysis of the case.
Our service aims to provide full clinical care of syncope including diagnosis and therapy.
A schoolgirl aged 16 presented syncope up to six per day seriously affecting her school attendance including sport being disallowed. A neurologist had already eliminated epilepsy.
Treatment with fludrocortisone 100mcg/day had no effect. Full history revealed no additional information except that she claimed that she enjoyed school but was approaching exams. Physical examination, supine/erect blood pressure and ECG normal.
Tilt-testing showed a panoply of findings. A vasovagal (VVS) tendency was revealed from the BP oscillation and it was considered by the staff that syncope was imminent. The heart-rate changes are compatible with postural orthostatic tachycardia (PoTS) but the patient had no other features of this condition. The frequency of syncope suggested psychogenic pseudosyncope (PPS). Thus two diagnoses were made PPS and VVS.
Her condition was discussed with her and her family. It was agreed that she would take Ivabradine 5mg daily increasing in 2 weeks to 5mg twice daily. She had close and supportive follow-up with the full benefit of education about both VVS and PPS. She had no side-effects of medication. Her symptoms subsided progressively. Her school attendance increased back to normal. Syncope ceased. After six months treatment it was possible to phase it out over a further six months. She again took up sport with success for her school. She passed her exams with credit.
Implications of the case
Frequent syncope is very often PPS but its origin is usually VVS so both conditions exist together and evidence of this can be seen on tilt-testing. Even a diagnosis of PPS does not require a referral to a Psychiatrist as close supportive care based on patient education and empowerment can achieve excellent results. Not every patient with excessive heartrate on tilt has PoTS.