Chapters Transcript Video Syncope So, uh thank you everyone for uh um logging in and logging and uh you know, being allowed to um speak about uh syncopy with everyone on the call and uh rather informal. So please um feel free to ask questions and use the chat and I will try to address them as uh well and honestly as as possible. Um So first off, just the disclosure about uh pediatric syncopy, uh I have no financial relationships. Uh I will take uh any applications if anyone would like. Um but um there is no financial uh you know, incentive for me to do this. So the objectives of our talk today is really determining what's normal and abnormal. So by far and large, most of the times we encounter sick could be, it is vasovagal. Um But from my vantage point and granted, I might be biased from uh my uh background in training. I am most concerned about whether there are potential substrate of sudden cardiac arrest. Uh What I think is also really helpful and perhaps really reassuring for a lot of families being able to identify potential concerning family history in terms of identifying uh unusual forms of syncopy. And in which case, that can lead us to being able to really reassure families really well and really emphasize that, hey, these are conservative things that we can do. These are the things we're kind of looking out for. These are the types of things we've already assessed for. And this is why your child is doing quite well. So before we kind of go into the nuts and bolts and uh what is abnormal and what is normal? A few examples and uh apologies if this comes out a little bit on the loud side, few other examples contrasting this and we'll revisit those videos. Uh at the end. Um Each there are both an equal, there, there's an equal mix of both abnormal and normal syncope uh that will go over. So in terms of definitions, just make sure we're all on the same page. Uh What does thinking mean? So practically speaking, these are other terms that um a lot of our patients may be approaching us with. Um And in terms of what the dictionary um says, well, it's pretty on point uh to be quite honest. Um The way I kind of phrase it in my mind is loss of conscience uh due to uh inadequate super, really only has to decrease 30 to 50% below baseline for this in order to occur, at least in terms of vasovagal syncopy quite prevalent. So we estimate that about 15% of Children adolescents, a quarter, college students, 47%. And no, I do not know how much of that is related to alcohol lifetime. Uh probably at least 50 at least half of us have had this at some point in time in terms of how many times urgent care, emergency department visits are needed. Fair percentage uh in terms of who seeks uh attention, uh relatively small numbers. Uh granted these are fairly old numbers, but I don't think things have changed too tally much over the years in terms of how much is being assessed. Well, uh 40% hos uh 40% do get hospitalized when they do present to the emergency department. Uh One of the things I find interesting is how much we are investing in terms of the assessments and particularly as time progresses, I think there's more and more attention placed in terms of effectiveness, particularly from a financial standpoint in terms of our assessments for conditions, particularly where things are normal and where reassurances are for the most part needed. So kind of to give a sense of what our understandings of syncope, what the potential causes are. So we've known predominant most of the causes for very many years. So this is from the early two thousands and the reasons for me kind of showing this here is um to kind of give a sense like what, what are the things we're kind of really worried about and also the landscape in terms of, well, how serious and how dangerous can syn can be be. So this was published in 2000 and in terms of uh what are the cardiac causes when you start seeing all the listings here, cardiomyopathy, complex congeal heart disease, coronary issues, myocarditis, contrasting all these different types of things. Cardiac sy could be all these different things we're listing here, noncardiac things. Well can be very concerning um in terms of how potentially dangerous, how potentially uh how morbid the conditions are the cardiac issues with. Well, look through all the things here are potentially much more catastrophic than the noncardiac forms. So, in my opinion, when we're doing a syncopy assessment, while understanding that the vast majority of the vasovagal, we really are looking for a needle in a haystack, the rare situations in which we are having a particularly cardiac abnormality that is explaining what's going on. Vasovagal. We oftentimes over the years have used many different terms. So not uncommon, what sort of folk for folks to use other synonyms, neurocardiogenic neuro depressor. To me, they're all variants of the same condition that we're talking about. Uh my rough estimate at least 8% of the time with syncom me, it's a vaso vasovagal etiology, um noncardiac ones, but non VSO V ideology potentially concerning but not necessarily or or very, very, very rarely uh lethal and excessively morbid neurological metabolic forms, the cardi ones, those are the ones, in my opinion, we need to be very, very cognizant of very careful of and hopefully identifying these before something um catastrophic occurs. One of the things that always stuck with me ever since my general pediatrics training is uh the phrase that Children aren't little adults. So to give you a little bit of sense of why I think health care costs are a little bit excessive particular pediatrics at syncope. Well, this is how an adult emerging doctor could be approaching syncope. You see, yes, we all start uh with a history of physical and EKG, but we start looking at all the different tests that can be used here and we can really be going down a a really, really deep rabbit hole in terms of our um assessments, particularly if we use an adult road map. So what testing makes sense because it's one thing to say we want to be very targeted, but we should know what's gonna be high yield. Um My opinion, uh a tilt table test almost, almost always very limited uh utility. You can see the positive rates and, and the uh sensitivity and uh that can be helped that that has been reported in the past with the uh uh uh head upright tilt test. Uh If anyone's ever seen one, it can be a really brutal test. And it's one of these things that I I would be very hesitant to ever subject a child to. How about an echocardiogram? Um because you know, we wanna know if things are structurally normal or abnormal. Well, to me, I think it's very limited in scope. Um You can see the numbers here and the, and the, and the authors provided the percentages there in terms of finding something abnormal, 18% is uh pretty, pretty darn low sensitivity right there. To me, what's even more concerning is that the negative predictive value, it's only 96%. We want that number to be much, much, much, much higher. So I think the takeaway from looking at this study in these numbers is an echocardiogram is not gonna be particularly helpful, can be done. It just, it's just unlikely to be particularly helpful, but what can be helpful. Well, good history, physical exam EKG comparing the two numbers, we go from a sensitivity comparing to just an echocardio alone sensitive 18% to 96%. A negative predictive value going from 96 to 90%. To me, this is a much better um um direction and and the strategy in terms of of the assessments. So going more into detail like, oh, how do we approach a history and physical? Well, we shall also know what we're gonna be uh expect when we start getting a history, understanding what the uh the patient and and the family may be thinking about. Well, honestly, every single time and all of us who worked with uh younger patients, every single child, they're always wondering like if I'm gonna get shot, um, if they're gonna get a vaccine, oftentimes, a lot of adolescents are trying to uh um there is the potential for secondary game in terms of getting out of school. Really, the parents are just most times wondering what's going on with their child. And we just have to explain what we're thinking and what we're assessing for. Um for uh a lot of us who are consultants and such is, well, we wanna kind of keep keep this from happening from my vantage point as a cardiologist. My big target is, is there a substrate for sudden cardiac arrest? And do I need to be treated that? So, history wise and, and I love this quote just from, from Edmund Burke because it just to me really emphasizes just being very old school with medicine, just getting a good history uh and, and, and a good physical exam. Um So the types of things that are gonna be really helpful in terms of assessing, particularly looking for vaso vgo syncopy. What is a pro what was happening beforehand? Where the positional changes? What was the patient feeling beforehand? Are there other predisposing factors from a psychosocial standpoint to um to consider was how was the recovery was spontaneous? Oh my goodness. Was there CPR was it appropriate to have CPR uh and such have there been repeated episodes? The thing could be uh were they all similar? Were they different? Certainly having a witness would be very helpful as an independent observer to correlate what the patients experiencing. Um Most of us understand that there can be a lot of Coron vs in terms of past medical history. I think it's equally important, perhaps even more important to get a very detailed family history, particularly targeting the potential for an inheritable cardiac substrate and cardiac abnormalities. Um Sometimes the way we ask these questions uh can be pretty uh can, can be refined a bit more so and, and make it a bit more high yield and certain things as in asking very specific it is anyone in your family have a pacemaker or defibrillator. Um The thing that can be really, really helpful is asking inquiring about the potential of any family members who've died suddenly and I'll provide a little bit more detail uh as we move forward through the talk here. But before we go to the abnormal parts, let's just kind of get through the parts that are in terms of the most common forms of s vasovagal, the typical drum dizziness, you can read all the different thing, but this is lightheadedness. Uh all these preceding things that patients get, it sounds like something is about to happen, something is about to happen and they're not necessarily feeling something specific in terms of their heart rhythm beforehand. Uh Usually the patients will remember this program and they'll be able to, particularly with little bit prompting, they'll be able to tell you and confirm like, yes, this is the project. These are the things I was feeling beforehand, typically loss of conscience in terms of objectively measuring how long it occurs usually in the older seconds. Now, if one is observing one of these patients having it, um it can seem a little bit longer. Uh what can be also helpful in terms of having reassuring findings is having a witness who says they saw exactly how the patient looked, having a really pale appearance. Uh patients having the recall saying, you know, I was really, really cold, I was feeling really, really sweaty when this uh right before this occurred, can be very um helpful in terms of uh confirming uh a vasovagal syncope um diagnosis, recovering these situations, assuming that the patient is being uh laid flat and is uh o on the ground. It's usually spontaneous. The exception to the rule is sometimes when patients are being caught and instead of being held to the ground and lay flat, sometimes people are held upright and it's as if one is a similarly uh uh upright tilt test and they have recurrent syco. So that's the exception to a rule of the spontaneous recovery, very common in the recovery for patients. And not quite you taking at least seconds, not minutes until they're kind of feeling back to their baseline until they have uh the ba uh normal cardiac output for a while. So that can be anywhere from five minutes to 30 minutes, sometimes a little bit longer depending upon uh the pre seating circumstances. So, what is going on physically when this is going? Uh But uh when the patient has these symptoms, well, oftentimes there may be a predisposing of vs motor stimulus. So, pain, motional stress, um things are that are uh contribute to higher vagal tone uh uh are oftentimes uh observed. Other times it can be vasal dilation of the peripheral bala. So, not uncommon at all for patients to be standing for a long time or they suddenly uh uh stand up in recovery. Very common for patients to have a reflex, mild degree of uh of tachycardia. Uh The reason why patients typically will recover very quickly and this is probably something to be really mindful of and, and emphasizing for patients is getting to a supply position helps increase the systemic turn can help them feel better, much quickly, much more quickly. If there would be an at risk population, traditionally, folks would say, oh, adolescents, particularly females. Uh I've always kind of thought that being a little bit misogynistic. Uh I honestly, there's nothing specific about being female that I I perceive to um uh have them be more prone to this uh whatsoever. So, um but just to kind of make sure that people are aware like that has been thought of in the past. Although I don't, there's nothing inherent in terms of treating vasovagal syncopy most of the times, it's just education, really kind of talking with the patients like, hey, this is what's happening, this is what's physically going on uh beforehand and reassuring patients like no, we're not missing anything particularly dangerous here. Adolescents who tend to be the vast majority of the patients who have um syncope. A lot of times it's just uh helping them get and gain the insight that, you know, you drink a lot more fluids, you've had enough of fluid intake, chance of this happening, going to be much, much, much less. Um it can be particularly in the current day with a lot of patients having experiences like anxiety, food insecurities and things of that nature, skipping meals uh can be predisposing for for this um younger Children and adolescents understanding like, hey, this is how the body works when you stand up, very kind for uh for you to feel pretty dizzy with this. Um It's OK to sit back down, recognize your early pro drums and saying, hey, these are the times where you may kind of feel this a little bit more. So make sure you're cognizant of it, make sure you take the appropriate actions. And what I found to be really helpful for a lot of patients is helping them understand, OK, these are the parameters in which we know that this is can be can be normal, commonly experienced, really helping patients identify these are the potential symptoms that are really worrisome that change the tenor, change the framework in which we're thinking about syncopy. And these are the times to really let us know and say a much more intense, much more thorough evaluation is needed in terms of medications. Really very rarely will we have to actually prescribe something very specific, increased fluid intake by far and large for vast majority of patients is gonna be sufficient. In addition to a uh augmenting the education reassurance, sometimes augmenting that uh recommendation with a little bit of salt intake, not necessarily excessive, but just say be a little more liberal with it sometimes can be helpful years and years in the past. Um It was fairly common practice for people to prescribe um salt tabs and such. I I think that's probably a little bit excessive in the current era. Um but usually just having a bit more salty snacks available, I think would usually be pretty reasonable for most patients that said if one was interested in, in uh understanding what are some potential medications that we have used for uh vasovagal syncope. Uh These are, this is a table of all the different possibilities uh in terms of what is most commonly used flu or Cortisone, at least in my practice is one of those medications I tend to uh go to quite a bit relatively low risk, uh helps increase this uh sodium reabsorption and retention and can help the intravascular space. Be a little bit more effective. Uh I personally not a particularly strong fan of mita although you will encounter uh or may encounter uh other providers who tend to be quite uh strong fans uh of that. Uh One of the reasons I'm not particularly um uh a fan of using that is that it tends to result in unregulated high blood pressure, um resulting in a lot of headaches. And oftentimes, I feel like it does a bit more harm than the benefit uh beta blockers to tell them of trouble and and Penol if can be helpful. Uh If there is the sense that uh patients have inappropriate tachycardia, predisposing them to having this and that starts kind of pushing us into the arena of what I term vasal motor instability. But uh tiktok loves to uh term pots, which is a whole another big discussion uh which can also be approached at some other uh time point. Uh One caution I would have for uh everyone um listening today is to be understanding that there are limitations in terms of our treatment modalities. So even though I'm a particular fan of fludrocortisone, uh I also and I I try to be pretty um open with patients about it, I try to tell me nothing is perfect. So fluid card while it may help when you know, based on this diagram here, it does help somewhat, nothing is perfect, right? And this is uh adult data here um with uh risk ratios. So if things are totally ineffective, we would see that risk ratio staying close to one, if things are super duper effective, then we see that risk ratio of getting closer, close to 0.1. And you can see multi multiple studies here we try lots of different things. Yeah, there's always gonna be a failure rate. So we do have to be kind of cognizant of that from the get go. We, you know, we try our best uh we give the best advice we can possibly give, but at the same rate, we need to be cognizant that, you know, there are limitations to how much we can and can't do. And so for me, I I tend to think of this is just trying to communicate and try to be um as best as possible in terms of providing reassurance, but also in terms of educating fa uh families and patients like this is what's gonna give you your best shot of kind of being more healthy, avoiding these episodes. Uh all. And perhaps one of the reasons why I think I emphasized it a bit more. I know if I don't spend the time with that uh with the patient and we explain that there is a pretty good chance that uh we're not, we're gonna have a pretty low success rate here. So all that said, all those preceding things in terms of normal. So getting into the abnormal causes the things we really need to be screening for from a cardiovascular standpoint, impaired cardi abnormal cardiac output. Those are the types of things we need to be very cognizant and looking for card cardiac output, inherently high risk of P confusion and to kind of pare it down to kind of the bare bones kg. Put ways thinking about it, heart rate, function of heart rate and stroke volume. So heart rate, we can be talking about inappropriate bradycardia or sinus arrests stroke volume. Can it can be very much um impacted by having obstruction or poor cardi function. Examples of Brady cardio admiral bratic cardis. So this is an EKG and we can see P waves throughout the rhythm strip here that have no correlation to the ventricular contractions represented by the CRS complexes here. So this is an example of congenital complete heart block. Um And uh fortunately, we don't tend to see that as commonly. And it's usually something that uh adult providers tend to have to be more cognizant of. But these types of things have happened before, I guess. Uh it is possible for this uh to have been missed. This is an example from a patient who really did not like it when the EMTS came by and placed an I to place an IV in them. And this particular patient uh basically breath held uh and held her breath. And you can see the P waves going through here all the way through and through and she was able to hold her breath and vagal innervate down enough that she was able to suppress uh avi node function for a good long while reviewing cardiac obstructions that can potentially result in synchrony by far and large. The ones we are most worried about involved, the left sided heart left in tr a track and one way of organizing our thoughts is to think about it as either below the valve subvalve at the valve super valva. In terms of what those potential conditions are, you can see them listed on this uh on the slide here. Uh Yes, possible for right on geo ayat tracks um to result in syncope, at least in my practice, fairly rare. Um They're more likely to cause exercise intolerance than necessarily be but could happen. Uh If it, in terms of reversibility, things that kind of come in and out, perhaps um uh provoking a significant pulmon hibernation could be one of those issues. Fortunately, fairly rare um issue that uh could be encountered, the ones that we tend to get really, really concerned about involve poor myocardial function. Uh because that certainly can pretend uh future um arhythmic events and very dire circum circumstances and outcomes in terms of uh inherent abnormalities within the myocardial function. Generally, we big grab bag term for that cardiomyopathy. There are many different forms. So this is a suggested way of um of thinking about the different forms, either hypertrophic being abnormally, too thick dilated. So primarily the chamber is excessively large and that the muscle itself is excessively thick. There are also other ideologies, uh arithmetic, rven dysplasia. Uh nowadays, uh turn more arrhythmogenic right, venture cardio uh relatively rare um form. But one area of potential concerns, particularly the older we're talking with patients can be patients that have tachy metic cardiom. So these are typically patients who are either very, very young and, or having the inability to express um sensation of sustained palpitations. In which case, they can't have cardiom. Uh Certainly kalar heart disease is an area of concern. Uh both palliated and and unp forms. And then the other one to be cognizant of is myocarditis and uh abnormal typically infection, but oftentimes autoimmune disorders that result in excessive inflammation of the heart. So, examples of um that prior slide. So this is a still frame of an echocardiogram, a personal long axis form. So, orient one. So this is an entire uh uh and posterior we have the right ventricle being the an anterior chamber, left ventricle here. The inner ventricle septum typically is fairly similar in size to the left ventricle free wall. And this is a typical example of hypertrophic cardiomyopathy. And looking at this one can understand that the left outflow tract being over here. When the um inner ventricular septum here is excessively thick. It can be quite difficult for blood to be ejected from the heart. Examples of palliative congenital heart disease with the increase of sudden death. Some of this could be influenced um by survivor bias. But this is traditionally what we think about the different forms here. A arrhythmia is the sur of syncopy, typically not life threating but could potentially result in syncopy SPT. So check the tech cardio uh other possibilities. Um uh idiopathic outflow tract ventri tac cardia uh can potentially cause syncope. The ones that are potentially life threatened that I would encourage everyone to be very cognizant. Uh of these possibilities are Wolf Parker and white WPW and will be generally uh put together and brought back term channelopathy. So, uh inherent anomalies of the card channels on a microscopic cellular level. So long QT syndrome entity called catechol catecholamine, polymorphic ventricul attack here. Uh A K AC PV T and Brugada syndrome and then lastly uh commercial Corts, let me see if I can demonstrate a few examples here. So in terms of uh arrhythmic potential causes, so Wolf Park is white. So this uh condition is due to an Atrovent accept pathway. So distinct extra nerve fiber between the top and bottom chambers separate from the native normal atrial ventricular node. One can see here that there's a very short pr interval with the correlation of a slurred up slope for the cure restoration. Uh A K A delta wave patients with little Parks and white do have a risk of sudden death from what's generally termed RBRVR rapid ventri response to an atrial arrhythmia. That risk is approximately 0.3 to 3% over a lifetime. Thankfully, most of these patients typically present with SVT symptoms rather than RVR of an atrial arrhythmia. The most common form of channelopathy, at least in the current air of medicine, as we understand this Longyi syndrome. The best way to think about it is it's an abnormality in the relaxation phase from an electrical standpoint uh of the heart lifetime risk of torso, the points approximately 1% per year for each patient. Um This is Bizet's formula. He's uh the oh the doctor from well over 200 years ago who um came up with this form in terms of more normalizing our measurements of the QT interval. What's really important to understand is that also somewhat dominant, inherent uh condition. So this is where asking the right questions from a family history standpoint can be potentially very helpful in terms of triggers as opposed to vasovagal syncopy where patients tend to be in a uh or almost uniformly or in a relatively restful state, long, complete opposite end of the spectrum. They, in terms of the three most common forms of long tal with also understanding that LQT one and two are uh even higher um percentage of those patients, they tend to have an abnormal response to sympathetic nervous system, the fight of flight response. And that's one thing to kind of keep mindful of is abnormal response to fight or flight response. Then cardiac, that also includes a catacomb new polymorphic ventricular tachycardia. Um I will come back to the uh uh questions answers in a little bit. Um C PV T um This is one that's I think it's very challenging for all of us is that um um it's an abnormality to the fighter polite response. The reason why this is so challenging, so difficult because one just has to be cognizant of it. It's all history. In other words, we're not, we're not gonna find anything suspicious. Physical Sam, the EKG is gonna be totally normal. At least the resting EKG, any imaging study that we even tried to kind of get, we will not find an abnormality. At least one that correlates with this, what's potentially helpful in diagnostic in this case. And I think it's fair to say that any person who has had a loss of consciousness in response to fight uh in, in terms of a uh a startle or uh exercise uh situation where there's a um activation of the catecholamines, they should get an exercise test because one might be able to pick up on this by looking by seeing uh an abnormal ventricular arrhythmia during that time. And the classic case of this is what we term bidirectional var tardia where the wide complex tachycardia, it rotates on the axis from one beat to the next beat over and over again. Even if we do genetic testing genetic testing is very expensive. Uh, it is not that terribly high yield. The sensitivity is roughly about 50% perhaps a little bit higher in the current e but not much. So, one reason to be aware of this is while most patients are older, if they have symptoms, at least based on this study, uh, a almost a third of them will have symptoms, um, by the, uh, with, um, within the first couple of decades of life for one decade and have a higher percentage just once gets into two decades of life. Another channelopathy, thankfully, uh little uh both CP BT and BRAGA, relatively smaller um Brugada syndrome and as opposed to um Monkey T syndrome, which is a loss of function. The potassium channel braga is the loss of channel of the sodium uh sodium channel, hopefully presents asymptomatically and it's mostly the cascade screen that we identify these patients. Vast majority of patients who have a cardiac event will have a cardiac arrest during sleep or, or arrest like Long KT syndrome or some dominant hair. This pattern. There are very typical EKG findings that can help one diagnosis. Uh One thing the cognizant of particularly for all of us, working with younger kids who tend to have a lot of fevers. Uh is that the EKG abnormalities and arrhythmias tend to be most pronounced or oftentimes pronounced during fevers or provoked by fevers. This, these are examples of long, the one I would encourage all everyone in the audience to uh be cogni stuff and recognize. Remember from this is type one, which tends to have the highest risk of having mericle arrhythmias. And the thing to keep mindful of is a downward sloping ST segment elevation. And the reason it's so important is in terms of the Multivariate analysis and uh who's at most at risk you can see here, it's patients who both have syncope but also a type one EKG pattern. So these are the patients who are at highest risk for having a potentially life threatening event. Lastly, the most unlucky of unlucky causes of a tri arrhythmia that can result in loss of conscience is commercial chorus. What I mean by the most unlucky scenario is that all these things have to happen, there has to be sufficient trauma that just happens to occur over lying with the myocardium is with sufficient force to result in a um effectively shock to the heart that just so happens to occur when the heart is rep polarizing self. So R on T so como cords ex exceedingly rare. But this is one of those things. If anyone of us who have kids who are on the sports field and sees someone sustain uh a hit to the chest, particular the left side of the chest, we need to be and see them collapse. We need to be cognizant of it and ask the patient to run and get the defibrillator and, and really think about CPR right away. So with all those kind of scary things, where are the can't miss clues? Well, patient history, certainly. Congenital heart disease, certainly. Oh, I, I like, I like to thank all of my colleagues in cardiology. We are always willing to kind of answer questions. So if there's concern, please reach out um programs that can be suspicious for non uh congenital heart disease, palpitations beforehand. Um fight or flight response immediately preceding the single episode, uh syncope that is occurring with increasing assertion. Those are all things to be caught some and be worried about a cardiac cause. Certainly abnormal EKG uh can be potentially very, very concerning. I am an advocate for identifying family history that would um that can help frame how we think about the syncope in the patient in front of us. Uh Hopefully, there are families who are in sight who understand what their medical conditions are, how that has implications for their Children doesn't always happen. But oftentimes patients will give us some few clues. And what we're assessing for is are there any sudden deaths, particularly first group family members? But sometimes it can be grandparents, aunts or, or uncle and that leads us um to asking the right questions of the parents and going from there. So the ones that are not so obvious and hopefully uh uh these can uh we can augment our history uh taking to be able to uh make our history and physical a bit more sensitive are abnormal seizures that are either unresponsive to medications worsening exercise to can be a sign of cardiom, uh, poor growth and development, uh, could be, uh, another potential sign here. The family history, unexplained deaths, drownings, uh, unusual car accidents where someone was a driver, uh, sudden infant death, particularly outside of, uh, the first few months of life can be a potential concern. The patient uh whose parent has had multiple miscarriages could be potentially concerning for this. Uh a parent who's had frequent syncopy and or seizures that are relatively unexplained can be concerning uh a lot of times patients, they may not know specifically what their family member has been diagnosed with, but they often times remember if there's a scar uh overlying their left shoulder can be assigned a pacemaker or a defibrillator. Uh particularly if that family members can articulate that they know that their family did not have ischemic heart disease. That is doubly concerning for the potential for an inheritable cardiac rhythm substrate, quote unquote heart attacks under 40 years of age, theoretically possible, extremely rare, but I would be very concerned that uh what the family is terming heart attack is really an aborted cardiac arrest. So um in terms of final thoughts, while the last 20 slides I kind of went over are all very worrisome. Things was a uh uh cardiac syncope. Please keep mindful that most causes of the sync that we're seeing use vaso. Um But what we need to be looking for the cardiac ideologies that I think particularly when you can articulate to feel like, well, these are the things that are really dangerous and this is why I know your, your, your, your love one, your child does not have that can be really helpful in terms of reassuring uh families. The history is the key. Um Remember SYN can be necessarily a large events, often abnormal family history, almost as important as the the patients of history in front of us. I'm very much an advocate. History is gonna be much, much, much, much more helpful than, than testing per se. With the caveat of saying that the ECG can be potentially very helpful in that assessment. Um Since we have a little bit um before I kinda go through those prior um uh um slide uh videos here, let me see the questions here. Um So first one here is if the EKG is uh is normal, when would I recommend a holter monitor? And um what can we eat? Uh uh exclude with a single EKG uh doesn't need uh monitor the halter. Um So if the EKG is normal, I rarely, rarely will, will suggest uh if the EKG is normal, I will rarely suggest a holter monitor unless, and it's extremely rare when this occurs unless the patient is saying, oh, I have fainting pretty much every single day or I have a seizure every single day and I'm, I'm not sure. And, and, and we're in a particular scenario where someone may have a seizure disorder, we're not too terribly sure that we're not missing some sort of entry claim in that context. Maybe a holter marker could be helpful. Otherwise, uh I think the whole of marker is helpful in very specific circumstances. Um in terms of assessing in particularly if we have the concern of the possibility of uh wolf parks in white. So let's say the EKG is abnormal at baseline. Sometimes the holter market can be helpful in terms of uh what we broadly term risk assessment. How is this one of those potential 0.33% of the time where as someone with wolf Parkson white uh has a potentially dangerous nerve um Holter monitor can be helpful in the context of someone who we are highly suspicious of having long Qt syndrome. There can be findings on a holter monitor that can be supportive of that diagnosis. Um Otherwise, the whole to monitor just in terms of an empiric or universal kind of use uh is probably of limited scope and limited benefit and repair to a large VSD is at risk for syncope. Um And uh what about can be closed with ac um theoretically that can be possible uh in terms of surgically repaired. Um DS D, there are two possibilities that that that can occur and some of it just kind of depends upon where the exact um repair was done. Uh by far and large, the way it's approached from a surgical standpoint is that um the surgeon approaches the VSD through the right atrium makes an incision a right atrial, right, right atrial oy. And as such results in inherent scar in that region, and these patients can have a slightly higher risk of having atrial flutter. So that's possibly particularly if there is rapid venture response could potentially result in a vast enough rate that can result in syncope. Uh tank fly is pretty small over the years. I think I've seen two cases um at least with VSD uh in of itself um tends to be pretty small. The other possibility is um with the patch closure and we can extend this to saying in uh having it close within ac lab um with a uh device uh theoretically whenever there is differential um conduction and innovation of the ventricles that can result in a reentry arrhythmia, uh that possibly tends to be pretty small. We generally do routinely screen patients for that possibility with holter monitors at uh just elective interval uh uh time points. Certainly, if there's syncopy, I think that would be uh a very reasonable indication of for, for doing that in terms of cath lab closure of ventricle self defects, some of that kind of gets into the weeds in terms of the techni uh technical um placement of these uh VSC devices kind of depends upon how much of the myocardium is involved. Whether or not there is a lot of aerial tissue with the truss in which the device sits in. So the device doesn't sit so much in within the myocardium, um so hard to give total blanket answers. But I think it's very reasonable in that scenario to, to have it assessed though either. And I would say probably both with echocardiogram to make sure the device is still in the correct position. And does it hasn't had any erosion through within the uh through the heart? Uh And also with um cardiac rhythm monitoring. Um let's see here. So with that, let me go back. 00 Any roles for s uh for labs with syncope? I think if one were concerned for the possibility of perhaps someone having a anemia uh and that could be contributing for it, that would be a reasonable thing um to consider uh if one had other concerns. So let's say like palpitations, you're worried about hypothyroidism potentially. Um The other scenario in which that could be helpful is if one has the suspicion that a patient has a very poor routine oral intake, uh getting a um a basic metabolic panel with the uh and looking at the bu and decatur ratio could be helpful in that standpoint. So if that b Unrein ratio is particularly high, that could be helpful in terms of um uh of, of thinking that a patient may not be um hydrated sufficiently. Although quite honestly, I think you, you could probably get the same information just from a urinalysis and just seeing uh what the, the spec graph I is there. And uh uh and understand that I, I generally tell patients, uh, when I'm counseling about like how, what degree to be hydrated with, I just tell them, look at the, look at your urine, uh how dense it is. If that urine color is, tends to be really, really pale yellow all the time, then you're hydrating enough. If it tends to be really kind of more yellow, particularly getting more dark to the point where it's getting kind of orange and that's pretty much a danger zone. Uh So oftentimes I, I empirically quote unquote treat instead of um just in terms of ordering labs, I mean, it's, if, particularly if you have another reason to look into it, sure, it's fine. But I, I don't think um uh uh routinely, I, I don't think it's necessarily going to be uh very helpful uh with that. Let me show you the prior uh examples. Um So this is an example, I think of uh vaso vagal syncopy, um seeing perhaps just a little faster but seeing one's uh oo own blood, being quite afraid of it and having a profound uh vagal innovation and then uh having um a transient loss of consciousness contrasting this one. Well, I'm sure the producers and the writers were saying, oh, I guess funny, funny. Uh I would argue that this would be concerning for a patient who has had uh has long Qt syndrome or cater, calling polymorph maar care fight or flight response and then sudden collapse to me. This is C PV T or Long Qt Syndrome until proven otherwise. And I would, I would have this patient have an exercise test just to, you know, even if everything winds up being negative and normal. II, I think of those possibilities to proven otherwise. Um I just like karate kid. But in any case, I I this is just supposed to be just for, for humor, but most of the contrast with this video. So until uh recent history with the, the, I think it's Mara Hamlin, the, the Buffalo Bills uh safety. This to my life was the only recorded uh case of commercial cordis uh which is um this is a view from a very, very long time ago, but unfortunately, this young man uh sustained a punch directly to the chest. It just so happened to be overlying the heart sufficient force R on T and the patient um unfortunately passed away um because this was only in the infancy of understanding about commercial cords. So this is Chris Paul who is a notorious flopper in the NBA. Um and nothing concerning from heart standpoint but contrasting. Uh So, uh if my memory serves to correct this uh this gentleman was Hank Gathers, uh who would have been the number one draft pick, um, in 1977 for the NBA draft, he had just caught an alley, oop, it was starting from back on defense and he unfortunately had an unrecognized hypertrophic cardiomyopathy and had a ventricular arrhythmia and did not survive uh his first, um, episode of ventricle tard associated with cardiomyopathy. So, another sport with flopping is, uh quite prevalent is a European soccer or soccer in general. And this gentleman was trying to get a call from the referees, but very different than this circumstance. So this player has loke T syndrome and it was identified um, before, uh, he played this particular game or actually this season and my understanding is that he had it diagnosed and his cardiologist, uh, cleared him to play sports as long as he had a defibrillator because his cardiologist understood that there was a specifically high risk for having ventricular arrhythmia. And what one sees with this video is that this player had a ventri arrhythmia collapsed, um, because due to the ventri liia and that uh, leg jerk that one sees is due to the defibrillator going off. And, uh, what I don't show after this is the player got up, walked to the sidelines. It was fine. I don't think they let him back in the game, but he was fine. Otherwise. Um, so with that, uh, I'm certainly happy to take any additional questions if uh anyone has it but um just to um um show some additional information, um this is all um piece of information about our center which um ok, welcome to contact any of us. 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