Q: I am a 73-year-old female in relatively good health but in December 2008 I awoke in the middle of the night with cramping. When I came to, I was on the bathroom floor with a badly bruised arm. My doctor said he thought it was a vasovagal incident so I finally forgot about it. Then in December 2010, the same thing happened but this time I came to face down in a pool of blood on my bedroom carpet with carpet burns on my face and a cracked nose. I have no memory of blacking out. This time my doctor decided to investigate further. I have had all the heart tests including a stress test, EKG, echocardiogram, and an ultrasound of my carotid arteries. They are wide open. I had a CT of my head and face.
I have never heard of vasovagal and since this last episode, I have been really stressing about it happening again. Why has it happened during the night? I’ve taken steps to make sure when I get up during the night (which I do a couple of times to empty my bladder), I make sure I am awake and aware of my surroundings.
I take lisinopril 10 mg and simvastatin 10 mg daily and amitriptylene 50 mg at night. I also take calcium and a multi-vitamin. I am not overweight and walk on a treadmill two or three times a week. I do not smoke or drink. I would like to know what you think and if there is any other test you would recommend. Thank you in advance.
A: A vasovagal episode is the most common cause of syncope (fainting) known. It occurs when the body over-reacts to specific triggers such as seeing an automobile accident, the sight of blood or other great emotional distress. Essentially, it represents a brief loss of consciousness caused by both a drop in blood pressure and heart rate that reduce the normal flow of blood to the brain for as little as five or six seconds, while simultaneously widening the blood vessels in the legs with spontaneous recovery. When an obvious trigger is present, the condition might be completely harmless and will not require treatment. However, you have now had two episodes that your physician correctly attempted to address by ordering appropriate testing.
Essentially, syncope is reduced to two possible causes – those cardiac related such as mitral or aortic stenosis and those non-cardiac related. Approximately one in four people with syncope are diagnosed with a cardiac-related cause such as tachycardia (abnormal fast heartbeat), bradycardia (abnormal slow heartbeat) or a valve disorder, and all potentially life-threatening forms are cardiac related. Non-cardiac possibilities can include subclavian steal syndrome, psychological triggers (such as the stress mentioned above), and orthostatic hypotension. The latter occurs to an individual upon standing when a person’s blood pressure drops dramatically. This is most commonly seen in older people and is often caused by such things as prescription drugs, diabetes, and several other medical disorders. Since your episodes take place at night, this is one possibility to consider.
My guess is you do not have an arrhythmia with either a slowed heart rate or tachycardia with a rapid rate since your physician would have likely picked up on either occurrence. Should he or she have any suspicions, perhaps a Holter monitor (monitors activity continuously for 24-48 hours) or event monitor (worn for an extended period of time during which the wearer activates the recorder when symptoms are felt) is in order; however, with your episodes years apart neither test is ideal.
Treatment to help prevent future episodes include blood vessel constrictors and antidepressants. On the home front, you might speak with your physician about the use of elastic stockings, doing specific foot exercises, or tightening your leg muscles while standing for extended periods of time.
The lisinopril you are presently taking is used to treat hypertension, congestive heart failure and for other purposes. Side effects of the drug are possible syncope and palpitations. Your amitriptyline, an antidepressant, carries the side effects of lowering blood pressure and causing orthostatic hypotension.
Since you remain concerned about future attacks, I recommend you return to your physician for a talk. If he throws his hands into the air and cannot help, request a referral to a cardiologist who might shed some new light on the problem.
