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.

This has never happened in the car but he is almost 60 years old and is not getting any younger. I’m afraid it will happen when he is driving with me or others in the car and he will hurt us or someone else.

He is very healthy and has high metabolism. He works as a packaging manager for a chicken processing company and then usually works on things around the house when he gets home. He only sleeps 5 hours at night but after work if he sits down, he will fall asleep.

He gets his teeth cleaned twice a year and flosses. He has sinus drainage a lot and has a sinus infection at least once or twice a year. Other than that he is very healthy. He exercises, but not consistently. He is 5’9” tall and weighs about 180 pounds.

Please let me know if there is something we can do at home to help him or if we should call 911 when it happens.

DEAR READER: Based on your description, I don’t believe your husband is having seizures that are causing him to pass out. While loss of consciousness can occur, seizures are more typically associated with rapid eye movement, muscle twitching, or shaking and many times end with sleepiness known as a “post-ictal state”.

That said, I do have an idea of what may be happening. The key is that you indicate it only happens when he vomits. For this reason, I believe your husband is likely passing out from over-stimulation of the vagus nerve. There are two vagus nerves in the body; one on each side. These nerves are very long, extending from the brain stem to the abdomen. They are responsible for regulating heart rate and blood pressure. During times of extreme emotional or physical stress typically caused by an external trigger, the nerve can malfunction, slowing the heart rate and drastically reducing blood flow to the brain, resulting in a faint.

Symptoms that can appear prior to a faint include, lightheadedness, tunnel vision, a feeling of warmth, skin paleness, nausea and a cold, clammy sweat. These are then followed by a brief loss of consciousness.

Common triggers include having one’s blood drawn, the sight of blood, straining (such as from a bowel movement), standing for long periods of time, heat exposure, and fear of bodily injury. Your comment about your husband having a virus and throwing up which causes the fainting may not be entirely correct. It may be that he is exhibiting symptoms of a vasovagal syncopal episode which may resemble a viral infection (fever, chills, sweats, nausea, vomiting, etc.).

In most cases treatment only involves identifying and avoiding triggers. When the sufferer feels a fainting spell coming on, lying down and raising the legs may prevent it. If he can’t lie down, have him sit with his head between his knees until the feeling passes. Beyond that, if episodes occur often enough to interfere with quality of life, medication, to include antidepressants and blood vessel constrictors may be beneficial. For some, pacemaker insertion has been found beneficial.

Other causes of fainting can include certain heart and brain disorders which can be much more serious.

Also, your husband needs to get more sleep at night. Humans need seven to eight hours of sleep in order for the body to function optimally. Clearly your husband is tired if simply sitting down after work causes him to fall asleep. He isn’t doing himself any favors by fighting to stay awake when his body wants, and needs, to sleep.

I urge your husband to speak with his physician about these episodes of passing out. As soon as a cause can be identified, steps to prevent further occurrences can be taken. The next time he exhibits symptoms and feels as if he is going to vomit, have him lie down and raise his legs. If his symptoms subside, great, but be sure to inform his physician. Also, ask him to try to remember what happened immediately prior to the feeling as this may help identify a trigger. If he does vomit and then faint, immediately call for help. Fainting is never normal.

On another topic: For all those elderly people out there who have “fainting fits,” the “woozies” or the “spins,” drink a couple of glasses of water. My dad used to conk out for no apparent reason, and it usually turned out that he did not consume enough fluids and overused laxatives. We would get him to the ER and after IV hydration, he would snap out of it. Removal of laxatives from the house and closer monitoring of his fluid intake helped keep him on his feet.

DEAR READER: Mixed connective tissue disease (MCTD) is an uncommon autoimmune disorder, meaning that the body’s immune system attacks itself. It is sometimes referred to an as overlap disease because it causes symptoms similar to those associated with lupus, polymyositis, scleroderma and, sometimes, rheumatoid arthritis.

MCTD most often occurs in women in their 20s and 30s. Symptoms generally occur gradually with signs of lupus appearing first in most cases. Most sufferers are first diagnosed with lupus because of this, but as symptoms progress, the diagnosis of MCTD is then made.

Symptoms may include Raynaud’s disease (which may present years before other symptoms), malaise (feeling unwell), fatigue, mild fever, swollen joints and/or hands, puffy fingers, myalgia (muscle pain) and arthralgias (joint pain).

There is no cure, but treatment is available. Mild cases may not require treatment at all. Moderate to severe cases may need daily medication with non-steroidal anti-inflammatory drugs (NSAIDs), such as over-the-counter ibuprofen or naproxen sodium and prescription ibuprofen, oxaprozin and others. These work to reduce inflammation and pain. Methotrexate and corticosteroids, such as prednisone, may also be prescribed. These drugs work to suppress the immune system, thus reducing inflammation and pain. Other immunosuppressant drugs may be used if symptoms are more like one particular disorder, rather than an equal or near-equal combination of them. For example, those primarily with lupus-like symptoms may benefit from drugs used to treat lupus.

There are no known risk factors for developing MCTD, and there is no known cause. Complications of the disease and its treatment can include heart disease, pulmonary hypertension, possible pregnancy complications (studies currently conflict) and side effects of long-term corticosteroid use.

Now to your advice regarding fainting. Dehydration can be a serious problem, especially when combined with laxative overuse. This is especially true in the elderly who may already be on several medications and have other health concerns. Laxatives should only be used sparingly, if at all (unless directed by your doctor), because they can cause dehydration and dependence.

To provide related information, I am sending you copies of my Health Reports “Managing Chronic Pain” and “Constipation and Diarrhea.” Other readers who would like copies should send a self-addressed stamped No. 10 envelope and a $2 check or money order for each report to Newsletter, P.O. Box 167, Wickliffe, OH 44092. Be sure to mention the title(s) or print an order form off my website at www.AskDrGottMD.com.

I am not convinced that vasovagal syncope is the problem because she is still having racing-heart episodes out of the blue. What other questions should I be asking her doctors?

DEAR READER: First, vasovagal syncope is the most common cause of fainting and occurs when the body reacts in an exaggerated way to certain triggers. These triggers cause a sudden drop in heart rate and blood pressure, which reduce blood to the brain, leading to a brief loss of consciousness. Because it is generally harmless, it typically does not require treatment.

Treatment may consist of blood-pressure medication (which blocks some signals that can lead to fainting), antidepressants, blood-vessel constrictors, certain exercises, avoiding prolonged standing, drinking plenty of fluids and finally, in severe cases, surgery to implant an electrical pacemaker.

I doubt this is your daughter’s problem because vasovagal syncope decreases the heart rate rather than increases it.

I believe the likely culprit is the H1N1 vaccine. According to the Mayo Clinic, you
should check with your physician immediately if you have chest pain, dizziness, fainting, fast heartbeat, feeling faint, dizzy or lightheaded, get hives, itching, shortness of breath, a skin rash and much more. These side effects are listed as having an unknown incidence rate, but clearly your daughter is having many of these reactions.

I urge you both to return to her pediatrician to discuss the possibility that she is having a reaction to the vaccination injection she received. If they will not consider it a possibility or don’t know how to help, consult another physician.

When it first started I was 69 or 70 years old. Sometimes I could feel it coming and was able to brace myself. Other times it would just happen and I would wake up on the floor.

I was sent to three different hospitals and had practically every test imaginable. Everything was normal. The black-outs then stopped in November 2007. I didn’t have another one for almost a year. In October 2008 I had three in one day. Two happened in my garage and other one in my bathroom. I got bruised up pretty good during one of them.

I have been reading your column for years and respect your opinion. I have also seen you pull many rabbits out of your hat and hope you can do the same for me.

DEAR READER:
Because you don’t say what testing you have had or what kinds of specialists you have seen I may repeat some what you have already had.

First, I would recommend you keep a journal of every episode you experience. You should write down the time it happened, what you were doing immediately prior and approximately how long you were out. This simple step may reveal a pattern that was previously unnoticed. You should also include whether you had eaten and any medications you had taken that day, prescription, over-the-counter, herbal or otherwise.

Next you should undergo heart testing such as an EKG, heart ultrasound, a stress test and an event monitor to ensure that your heart is functioning properly. A slow pulse, rapid heartbeat or extended pauses in the heart rate can cause black-outs and fainting. If your heart checks out okay, a neurologist is the next step.

This type of specialist can order sophisticated testing of your brain such as MRIs, brain wave testing and more. Perhaps your black-outs are in fact a type of seizure.

You need to determine the cause of your black-out episodes as soon as possible before you fall and get seriously injured.