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.

I am the youngest of 10. My mother passed away at the age of 44 when I was four years old. I’m approaching her age quickly and want to take steps to prolong my life.

DEAR READER:
First, let’s review your conditions.

Kidney stones are a common but extremely painful disorder. Most pass without intervention by physician assistance. Others don’t.

Auto-transplant means relocation of an organ, in your case it was your left kidney. There are a number of reasons that would warrant having this dramatic procedure performed, such as complex renal artery disease.

The most common cause for skin cancer is sun exposure in areas unprotected by sun block or clothing during outdoor or work activities.

Your mini-strokes resulted from blood vessel blockage in the brain. Similarly, a pulmonary embolism is blockage of the pulmonary artery or one of its branches. Both conditions are the result of one or more clots traveling from any part of the body to another.

The pulmonary embolisms likely led to stent replacement when a surgeon attempted to improve blood flow. A stent is simply a mesh tube that helps keep the artery open.

So far, your conditions are fairly easy to explain. Now comes the tricky part.

You say you have a Factor V (FV) clotting disorder. Do you truly mean that or do you mean that you have a Factor V Leiden (FVL) clotting disorder? The process of coagulation requires a delicate balance to ensure just the right amount of clotting power in the blood. Too little leads to bleeding problems; too much can lead to dangerous blood clots.

While both conditions have similar names, they are entirely different. FV is actually a bleeding disorder. It is rare and results from a lack of the protein Factor V which can cause excessive bleeding.

Factor V Leiden is not a lack of the protein but rather, a normal amount of abnormal versions of Factor V. This causes the proteins to work in the opposite way, causing “stickier” blood and, for some individuals, abnormal blood clots. These clots are especially common in the legs (known as deep vein thrombosis) or in the lungs, such as you have experienced during your many attacks of PEs.

With your history, it appears to me you are suffering from a factor V Leiden disorder. This condition can either develop during a lifetime or else it is inherited. A hematologist should be consulted immediately in an attempt to bring the disorder under control. By doing so, he or she should reduce or eliminate a lot of your problems.

Finally, as crass as it may sound, your forgetfulness may be the least of your many problems. Perhaps you are simply over-loaded with so many medical issues you are blanking out on names. Another cause could be damage to the memory storage areas of your brain as a result of your several mini-strokes. I recommend you see a neurologist who can perform appropriate testing to determine the cause.

You should be seeing a top notch primary care physician you trust implicitly who can orchestrate this plethora of problems. He or she should refer you to a number of specialists, including a hematologist, neurologist, pulmonologist, nephrologist, urologist, and/or dermatologist, all of whom can work together to provide you appropriate treatment for each of your problems.

Now, on to your laughter and passing out. Laughing predisposes an individual to an increase in venous pressure within the thorax. That pressure is a mechanism for syncope, a transient form of unconsciousness. Known as laughing syncope, the condition is seen in patients with arterial/vascular disease and not in those who are healthy. Since you have a great deal on your plate already, I’m extremely reluctant to suggest you refrain from laughter. Perhaps moderation is the key. Smile a lot, laugh with a little less vigor, get tapped in to the system of specialists who can provide you the best care possible, get that clotting factor under control, and approach and move beyond your 44th year with the knowledge you are doing all you can to keep things under control.

To give you related information, I am sending you a copy of my Health Report “Medical Specialists”. Other readers who would like a copy should send a self-addressed, stamped, number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

He will have to stand in one place with his hands against the wall for support until his vision returns. He has seen a neurologist and a cardiologist. The cardiologist suggested syncope (fainting) and the neurologist saw nothing on an MRI.

My son is desperate to find out what is wrong with him. After a little online research of our own, we are thinking POTS, or orthostatic intolerance. His symptoms occur upon standing. What do you think?

DEAR READER:
Some children and adolescents experience pre-syncope, a feeling they are about to faint. They may complain of dizziness and a feeling that the room is spinning. There may be episodes with adequate time to slump to the floor or sit in a chair, while at other times a person may fall to the floor without warning. The feeling is frightening for an adult and overwhelming for a child, so I can understand his anxiety.

An irregular heartbeat can be a trigger. When the condition occurs, the ventricles don’t have adequate time to fill with blood before that blood is automatically pumped throughout the body. The body reacts to the decreased blood supply by shutting down, causing fainting to occur.

Abnormalities in the structure of the heart can cause near-or-true syncope also. An outflow obstruction restricts the flow of blood out of the left ventricle of the heart. Certain cardiac conditions such as aortic stenosis or myocarditis will diminish the flow of blood through the aorta, causing symptoms of syncope.

A drop in blood pressure on standing or when a child has been standing for an extended period is known as orthostatic hypotension. Blood pools in the legs, preventing it from return to the heart in adequate supplies. Simply put, when the heart doesn’t get adequate blood in, it can’t pump adequate blood out. Syncope results.

The vagus nerve is essential for the function of numerous body parts. When stimulated by conditions such as stress or pain, blood vessels dilate. This leads to a slower heart rate in susceptible individuals, resulting in syncope.

Still other conditions such as inner ear disorders, low blood sugar, head injury and voluntarily holding one’s breath can create like symptoms.

A common thread to some syncopal conditions is an inadequate supply of blood to and from the heart. Therefore, I feel your son should be seen by a cardiologist who specializes in pediatrics. While I understand he may not feel comfortable in a “pediatric” setting, I feel he will be better served there. Based upon his history, he may require lab work, a tilt table test, echocardiogram, or other appropriate testing before an accurate diagnosis can be made.

Because I mentioned ear infections as a possible cause, I am sending you a copy of my Health Report “Ear Infections and Disorders”. Other readers who would like a copy should send a self-addressed, stamped, number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.