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POTS: A Little Known Cause of Extreme Fatigue

Everyone knows what being tired feels like at the end of a long day. But some people experience fatigue so severe and so seemingly random that it’s hard to describe. If that sounds familiar, there could be more going on than daily stress.

While there are many causes of fatigue, one of them is frequently missed and misdiagnosed: postural orthostatic tachycardia syndrome (POTS). Physical medicine and neuromuscular specialist Tae Chung, M.D., answers questions about POTS and extreme fatigue as one of its symptoms.

When is fatigue considered extreme?

There is no good criteria for assessing the level of fatigue — it depends on the person. However, most people know when their tiredness is more than a lack of sleep. Some of my patients remember the exact day they got hit with fatigue so overwhelming that they knew something was wrong.

How would you describe fatigue associated with POTS?

People with POTS experience fatigue differently. Many describe it as feeling beyond exhausted. It’s as if your energy is completely depleted. The fatigue is probably hundreds of times worse than your worst flu. People with POTS may also have trouble concentrating and thinking straight. Doing simple tasks may feel like you’ve just run a marathon.

This fatigue might come and go, hitting you without warning daily, weekly or less frequently. For some people, extreme fatigue lasts for days. Others may experience periodic “attacks.” It can come on at any moment — even if you just woke up. And there is no amount of sleep or coffee that can make it go away.

What is POTS and why does it cause fatigue?

POTS is a group of symptoms resulting from dysfunction of the autonomic nervous system. This branch of the nervous system regulates functions we don’t consciously control like sweating and blood circulation.

In people with POTS, more blood collects in the lower body when standing upright. The heart beats faster to pump it up to the brain, but with little success. The causes of POTS are unknown, but the problem is thought to lie in the communication breakdown between the brain and the cardiovascular system.

POTS-related fatigue is physical in nature and the mechanism behind it is not fully understood. It may have several causes, including your body working harder to move the blood.

What are other symptoms of POTS besides the extreme fatigue?

People with POTS may experience different symptoms to a different extent. These symptoms may include but are not limited to:

  • Dizziness when standing
  • Nausea and vomiting
  • Lightheadedness and fainting
  • Brain fog
  • Muscle pain and cramps
  • Headaches
  • Excessive sweating
  • Shakiness

Some people feel as though their heart is beating really fast or skipping a beat. This is called heart palpitations.

Is POTS more common in certain people?

There are no established risk factors for POTS. However, it is known to run in families, so it could have a genetic component. Researchers have also established a link between POTS and Ehlers-Danlos Syndrome (highly mobile joints). So if you have one of these conditions, you might also have the other.

A big group of those diagnosed with POTS is young women and teens. However, this doesn’t mean they are more likely to develop this condition.

Is it possible that I have POTS and was incorrectly diagnosed?

This is entirely possible. Given how common POTS symptoms are and how unfamiliar many doctors are with this condition, diagnostic mishaps happen. POTS is frequently misidentified as chronic fatigue syndrome, fibromyalgia, myofascial pain syndrome, anxiety disorder, ADHD, irritable bowel syndrome, myositis, etc. It is also possible that you have both POTS and one of these conditions, which may complicate the diagnosis. Sometimes people with POTS are told that “it’s all in your head,” implying that the cause of their symptoms is psychological. If you feel like something is physically wrong, don’t hesitate to seek a second, and even a third or fourth opinion.

How is a POTS diagnosis made?

Problems with the autonomic nervous system can be difficult to diagnose. The standard test for POTS is the tilt table test. During the test, you are secured to a table that tilts from being horizontal to almost a 90-degree angle. The test measures your heart’s response to switching from laying down to standing up. Some people with POTS faint during this test, even if they rarely faint standing up.

Although the test seems straightforward, many things can interfere with it. It’s important that a POTS specialist oversees it. It’s best to work with a doctor who has diagnosed and treated patients with POTS. This could be a cardiologist, a neuromuscular specialist or another doctor.

Is POTS treatable?

While there is nothing that can make POTS go away for good, there are ways to address the symptoms. One treatment option is a diet that involves increasing your salt and water intake. This helps your body retain fluids and increase the blood volume.

The other treatment is exercise — even though it may be the last thing on your mind. Pushing through fatigue is difficult, but exercise can help you maintain healthy blood circulation. Exercise should be prescribed and closely monitored by your doctor. It often starts as low-intensity exercise that can be done while you are lying down, and gradually increases as your body is able to tolerate more physical activity, although each person’s experience is different.

POTS treatment has to be tailored to address your specific symptoms and underlying conditions. Be wary of trying treatments you find online without consulting with your doctor. A treatment that makes one POTS patient better may make another worse.

Fatigue is significant in vasovagal syncope and is associated with autonomic symptoms | EP Europace

Abstract

Aims

To quantify the prevalence of fatigue and its severity in vasovagal syncope (VVS) and to examine whether fatigue severity associates with symptoms of autonomic dysfunction.

Methods and results

All vasovagal syncope patients diagnosed between September 2004 and March 2006 were included ( n = 140). Fatigue was quantified using the fatigue impact scale (FIS) and severity and type of autonomic symptoms by the composite autonomic symptom scale (COMPASS). Patients were considered a ‘responders’ if they were no longer experiencing VVS symptoms or ‘non-responders’ if VVS symptoms were on-going. The VVS cohort was matched, in terms of both age and sex, with a group of community dwelling controls. Ninety-six VVS patients completed questionnaires (response rate 96/140, 69%). Compared with matched controls, VVS patients were significantly more fatigued (26 ± 32 vs. 13 ± 14, P < 0.0001) and a significantly higher autonomic symptom burden (COMPASS total score: 34 ± 23 vs. 13 ± 13; P < 0.0001). Significant correlations were seen between the total COMPASS score and fatigue severity ( r2 = 0.4; P < 0.0001). Non-responders reported significantly higher fatigue and more autonomic symptoms than responders to treatment ( P ≤ 0.0001).

Conclusion

Fatigue is a significant problem experienced by patients with VVS and is associated with autonomic symptoms, the severity of which correlates with fatigue severity. These symptoms are especially profound in those who have not responded to treatment.

Introduction

Vasovagal syncope (VVS) is an exaggerated tendency to the common faint that affects all age groups. 1 It is not considered a condition with an increased risk of mortality or morbidity, although there is clearly a risk of injury as a result of loss of consciousness. 2 Vasovagal syncope can, however, be a severely disabling condition with sufferers reporting a significantly reduced quality of life. 3–5 Furthermore, those who remain symptomatic report significantly higher levels of impairment due to syncope, more fear and worry about syncope, and higher levels of psychological distress. 6

Previous studies have characterized the non-syncopal symptoms experienced by those with VVS and found using semi-structured interviews that 71% describe autonomic symptoms and three quarters experience ‘severe fatigue’ after events, 7 with 21% of the VVS patients (and no controls) fulfilling the symptom criteria for chronic fatigue syndrome (CFS). 8 In contrast, studies report that the prevalence of syncope and/or pre-syncope in those with CFS is between 40 and 90%, 9 , 10 with overlap also reported for other VVS-associated symptoms such as light headedness (96% of those with CFS). 9 Furthermore, the treatment of neurally mediated hypotension when found in those with CFS can be associated with an improvement in the symptoms of chronic fatigue, cognitive disturbances, and light headedness. 11 In addition, CFS affects 0.5–2% of the population who comprise a similar demographic group as those who experience VVS. Such a degree of symptomatic and demographic overlap raises the possibility that these two syndromes share a common pathophysiological basis.

Studies examining the underlying biological basis of CFS have historically proved complex and contradictory results; however, there is evidence that abnormalities of the vascular system and its regulation by the autonomic nervous system, especially in response to standing, may be a common abnormality in CFS. 12–15 It is this autonomic dysfunction that may link the two disorders in certain patients because this is recognized as a potential contributory factor in the underlying pathophysiology of VVS. 16 , 17 This study therefore set out to quantify for the first time the prevalence of fatigue and its severity in VVS, and to examine whether, as has been recently found in CFS, fatigue severity associates with symptoms of autonomic dysfunction. 18 Our hypothesis being that, as in other diseases characterized by hypotension, fatigue is common in VVS and is associated with autonomic symptoms. Lessons learnt from further understanding the symptoms associated with, and the pathophysiology of, VVS may direct intervention studies in CFS.

Methods

Participants

The study cohort was identified from our VVS database. Subjects were consecutive patients who had been seen in our unit with VVS diagnosed by symptom reproduction associated with haemodynamic change during head up tilt test. 19 , 20 Head up tilt test is performed in all patients who attend the unit with a clinical history consistent with VVS. The diagnosis is made when patients experience hypotension in response to head up tilt (and/or bradycardia) in association with reproduction of their presenting symptoms of syncope or pre-syncope. Other causes of syncope had been ruled out. All patients diagnosed between September 2004 and March 2006 were included ( n = 140). Symptom assessment tools were sent by post to all patients in May 2007 who were invited to complete and return the questionnaires using a pre-paid envelope. A review of the medical notes and details provided by the patient determined whether they were considered as ‘responders’ (i.e. following diagnosis, the standardized clinical intervention algorithm was applied and the participant, in response to this clinical interventional algorithm or spontaneously, reported a full recovery) or ‘non-responders’ (i.e. had on-going VVS symptoms). 6 For the purpose of analysis, the total VVS cohort was therefore substratified into those who had on-going symptoms (non-responders to treatment) and those who considered themselves asymptomatic (responders to treatment). The management strategy for this cohort is standardized and consistent, and it initially includes conservative advice, including specific advice regarding counter manoeuvres increase fluid and/or caffeine intake, followed 3 months later if symptoms persist with the commencement of medication, initially with fludrocortisone, midodrine, or selective serotonin receptor inhibitor (SSRI) as dictated by the clinical situation.

Those who had experienced on-going symptoms at the time of completion of the questionnaires (the non-responders) were further substratified into those who were continuing to experience syncope or pre-syncope (sensation of impending syncope).

The total VVS cohort was matched, in terms of both sex and age, with a group of community dwelling controls. The control group was recruited from the local population through advertisements by inviting people to participate into research in the autonomic nervous system. No selection was made on the basis of presence or absence of fatigue, VVS, or co-morbidity.

Symptom assessment tools

Subjects completed a series of symptom assessment tools. All are fully validated for self-completion, and the results were compared with an age- and sex-matched control population.

Fatigue impact scale

This is a 40-item symptom-specific profile measure of health-related quality of life, commonly used in medical conditions in which fatigue is a prominent symptom. The scale allows patients to rate each item on a scale of 0–4, with 0 representing no problem and 4 representing an extreme problem. Adding the scores for the individual items creates a total score. The higher the total score, the more fatigued the subject is interpreted to be. 21

Epworth sleepiness scale

This 8-item scale is designed to evaluate patients’ general level of daytime sleepiness. This scale is fully validated to assess daytime hypersomnolence. Patients rate the likelihood that they would doze off in a variety of situations, for example, in the car or in front of the television. Zero represents a situation in which the patient feels they would never doze off and three represents a high chance that they would doze off in the given situation. The scores are added together to produce a total score. The greater the total score, the greater daytime hypersomnolence the patient feels. 22

Orthostatic grading scale

This 5-item scale evaluates the frequency and severity of orthostatic symptoms, the relationship between orthostatic symptoms and other orthostatic symptoms, and the impact of these symptoms on the daily life of the patients, for example, on daily activities and standing time. Participants rate each item on a scale of 0–4. Zero would indicate that dizziness has no impact on their day-to-day life, whereas 4 indicates that dizziness severely interferes with daily life. 23

Composite autonomic symptom scale

A composite autonomic symptom scale is a comprehensive and highly sensitive assessment of the prevalence, degree, and association between symptoms of autonomic dysfunction. The COMPASS has been fully validated against laboratory-based haemodynamic autonomic function tests and has been used effectively in the identification of autonomic dysfunction in a wide variety of conditions. 18 , 24

The COMPASS consists of 73 questions that are grouped into eight domains relating to individual aspects of the autonomic nervous system. The eight domains relate to orthostatic intolerance, vasomotor, secretomotor, gastrointestinal (further split into the subdomains of autonomic diarrhoea and constipation), bladder, pupil responses (including focusing), sleep disorder, and syncope. The scale also included domains for male erectile dysfunction and ejaculatory problems which were removed due to suspected irrelevance and also in an effort to reduce the length of the questionnaire. Each domain is scored on the basis of existence, intensity, distribution, frequency, and progression of symptoms. The domains that were included were weighted according to their clinical relevance as described in the original derivation paper. The individual scores are then totalled to serve as an indicator of overall symptom burden. In all cases, higher scores were indicative of the greatest symptom load, with 179 being the possible highest total score. Two further scales (understatement and psychosomatic) were incorporated into the assessment and were scored independently of the COMPASS score itself. These scales were included in order to detect a tendency for participants to over or under report the symptoms they have. These validity scales served as indicators of whether the participant had actively engaged in the completion of the questionnaire.

Procedure

All patients who were included in the VVS cohort were sent the combined questionnaires for self-completion, which were returned in a pre-paid envelope. In an attempt to increase the sample number, a second set of the same questionnaires was sent out to all those who had not replied after 2 months. Consent for the use of data was implied by the return of questionnaires. The study was approved by the Local Research Ethics Committee.

Data analysis

Data were analysed using the Graph Pad-Prism statistics package. All total scores and COMPASS domains were found to be normally distributed, and comparisons were therefore made between the VVS patients and the control group using parametric unpaired t -tests. The only domains that were found to be skewed were the understatement and overscoring domains of the COMPASS scale; comparisons were made using non-parametric analyses. Correlations using appropriate parametric and non-parametric tests were then conducted to assess the relationship between the fatigue severity and each of the other questionnaires. Corrections were made for multiple testing (Bonferroni) and, therefore, a statistically significant result was considered to be when P < 0.001.

Results

Ninety-six patients with head up tilt (HUT) confirmed VVS-returned questionnaires (response rate 96/140; 69%). However, five were incomplete and therefore excluded from further study, leaving 91 (65%) complete questionnaires which were included in the analysis. In the VVS group, 44 (48%) patients presented with syncope, 14 (16%) with pre-syncope alone, and 33 (36%) with both syncope and pre-syncope. The demographics of the patient and control groups are shown in Table  1 .

Table 1

Demographics and mean ± SD of symptom assessment tools in the vasovagal syncope cohort compared with the control population


Controls
VVS
P
n  91  91  ns 
Age  52 ± 13  55 ± 21  ns 
Male  20 (22%)  20 (22%)  ns 
FIS  13 ± 14  26 ± 32  <0.0001 
ESS  3 ± 4  7 ± 4  <0.0001 
Orthostatic tolerance  5 ± 7  16 ± 12  <0.0001 
Vasomotor  0.4 ± 1.3  1.4 ± 2.4  0.0008 
Secretomotor  1.7 ± 2.6  4.4 ± 4.1  <0.0001 
Gastrointestinal  0.3 ± 1.0  1.2 ± 1.9  0.0004 
Autonomic diarrhoea  1.8 ± 3.5  2.2 ± 4.2  0.6 
Constipation  0.7 ± 1.6  1.6 ± 2.5  0.005 
Bladder  1.6 ± 2.5  2.1 ± 2.9  0.3 
Pupils  0.4 ± 0.8  0.6 ± 0.9  0.2 
Sleep disorder  0.6 ± 1.1  1.7 ± 1.9  <0.0001 
Syncope  0.2 ± 0.8  2.5 ± 3.6  <0.0001 
Underscoring  1.6 ± 2.2  4.2 ± 3.8  <0.0001 
Overscoring  0.1 ± 0.4  0.3 ± 1.0  0.3 
Total  13.0 ± 13  34.0 ± 23  <0.0001 

Controls
VVS
P
n  91  91  ns 
Age  52 ± 13  55 ± 21  ns 
Male  20 (22%)  20 (22%)  ns 
FIS  13 ± 14  26 ± 32  <0.0001 
ESS  3 ± 4  7 ± 4  <0.0001 
Orthostatic tolerance  5 ± 7  16 ± 12  <0.0001 
Vasomotor  0.4 ± 1.3  1.4 ± 2.4  0.0008 
Secretomotor  1.7 ± 2.6  4.4 ± 4.1  <0.0001 
Gastrointestinal  0.3 ± 1.0  1.2 ± 1.9  0.0004 
Autonomic diarrhoea  1.8 ± 3.5  2.2 ± 4.2  0.6 
Constipation  0.7 ± 1.6  1.6 ± 2.5  0.005 
Bladder  1.6 ± 2.5  2.1 ± 2.9  0.3 
Pupils  0.4 ± 0.8  0.6 ± 0.9  0.2 
Sleep disorder  0.6 ± 1.1  1.7 ± 1.9  <0.0001 
Syncope  0.2 ± 0.8  2.5 ± 3.6  <0.0001 
Underscoring  1.6 ± 2.2  4.2 ± 3.8  <0.0001 
Overscoring  0.1 ± 0.4  0.3 ± 1.0  0.3 
Total  13.0 ± 13  34.0 ± 23  <0.0001 

Table 1

Demographics and mean ± SD of symptom assessment tools in the vasovagal syncope cohort compared with the control population


Controls
VVS
P
n  91  91  ns 
Age  52 ± 13  55 ± 21  ns 
Male  20 (22%)  20 (22%)  ns 
FIS  13 ± 14  26 ± 32  <0.0001 
ESS  3 ± 4  7 ± 4  <0.0001 
Orthostatic tolerance  5 ± 7  16 ± 12  <0.0001 
Vasomotor  0.4 ± 1.3  1.4 ± 2.4  0.0008 
Secretomotor  1.7 ± 2.6  4.4 ± 4.1  <0.0001 
Gastrointestinal  0.3 ± 1.0  1.2 ± 1.9  0.0004 
Autonomic diarrhoea  1.8 ± 3.5  2.2 ± 4.2  0.6 
Constipation  0.7 ± 1.6  1.6 ± 2.5  0.005 
Bladder  1.6 ± 2.5  2.1 ± 2.9  0.3 
Pupils  0.4 ± 0.8  0.6 ± 0.9  0.2 
Sleep disorder  0.6 ± 1.1  1.7 ± 1.9  <0.0001 
Syncope  0.2 ± 0.8  2.5 ± 3.6  <0.0001 
Underscoring  1.6 ± 2.2  4.2 ± 3.8  <0.0001 
Overscoring  0.1 ± 0.4  0.3 ± 1.0  0.3 
Total  13.0 ± 13  34.0 ± 23  <0.0001 

Controls
VVS
P
n  91  91  ns 
Age  52 ± 13  55 ± 21  ns 
Male  20 (22%)  20 (22%)  ns 
FIS  13 ± 14  26 ± 32  <0.0001 
ESS  3 ± 4  7 ± 4  <0.0001 
Orthostatic tolerance  5 ± 7  16 ± 12  <0.0001 
Vasomotor  0.4 ± 1.3  1.4 ± 2.4  0.0008 
Secretomotor  1.7 ± 2.6  4.4 ± 4.1  <0.0001 
Gastrointestinal  0.3 ± 1.0  1.2 ± 1.9  0.0004 
Autonomic diarrhoea  1.8 ± 3.5  2.2 ± 4.2  0.6 
Constipation  0.7 ± 1.6  1.6 ± 2.5  0.005 
Bladder  1.6 ± 2.5  2.1 ± 2.9  0.3 
Pupils  0.4 ± 0.8  0.6 ± 0.9  0.2 
Sleep disorder  0.6 ± 1.1  1.7 ± 1.9  <0.0001 
Syncope  0.2 ± 0.8  2.5 ± 3.6  <0.0001 
Underscoring  1.6 ± 2.2  4.2 ± 3.8  <0.0001 
Overscoring  0.1 ± 0.4  0.3 ± 1.0  0.3 
Total  13.0 ± 13  34.0 ± 23  <0.0001 

The prevalence of fatigue, daytime sleepiness, and autonomic symptoms in vasovagal syncope

Vasovagal syncope patients were significantly more fatigued t (172) = 3.6; P = 0.0004 ( Figure  1 ) and also reported significantly higher levels of daytime sleepiness t (172) = 5.3; P = <0.0001 ( Figure  2 ) when compared with the matched control population. Patients were twice as fatigued as controls and experienced more than twice the average daytime hypersomnolence of the control group ( Table  1 and Figure  1 ).

Figure 1

Fatigue impact scores for the control group compared with vasovagal syncope patients.

Figure 1

Fatigue impact scores for the control group compared with vasovagal syncope patients.

Figure 2

Epworth sleepiness scores in ( A ) vasovagal syncope compared with controls and in ( B ) non-responders vs. responders.

Figure 2

Epworth sleepiness scores in ( A ) vasovagal syncope compared with controls and in ( B ) non-responders vs. responders.

Vasovagal syncope patients reported a significantly higher number of autonomic symptoms than the control group ( Figure  3 ). This is seen clearly from the COMPASS total score, which is significantly higher for the VVS patients than for the control population, t (170) = 7.4, P < 0.0001. In fact, patients autonomic symptom burden is almost triple that of the symptoms experienced by the control groups. This increase in autonomic symptoms was significant in all of the COMPASS domains, except autonomic diarrhoea, bladder, pupils, and over-scoring. These findings suggest that VVS is associated with a substantial burden of symptoms relating to autonomic dysfunction. As with previous CFS literature, which describes abnormal-dynamic responses to standing, one of the greatest differences seen between VVS patients and the control group relates to the orthostatic tolerance domain, t (169) = 7.4, P < 0.0001. Vasovagal syncope patients had mean orthostatic tolerance scores more than three-fold higher than controls.

Figure 3

Relationship between autonomic symptoms measured by the total composite autonomic symptom scale score and fatigue ( B ) in responders, ( C ) non-responders.

Figure 3

Relationship between autonomic symptoms measured by the total composite autonomic symptom scale score and fatigue ( B ) in responders, ( C ) non-responders.

The COMPASS also contains subscales which are designed to assess understatement and overstatement of symptoms severity. Vasovagal syncope patients were interestingly significantly less likely to understate their symptoms as assessed in this way than the population controls. Overstatement scores were slightly higher in VVS patients when compared with controls, although scores were below one in both groups (potential range 0–10), indicating very low overall impact from overstatement of symptoms. The difference here was non-significant.

The relationship between increasing fatigue, daytime sleepiness, and autonomic symptoms in vasovagal syncope

In order to explore the associations between increasing fatigue, daytime sleepiness, and autonomic symptoms, the fatigue impact scale (FIS) scores were then correlated with the Epworth sleepiness scores (ESS), orthostatic grading scale (OGS), and each of the COMPASS domain scores ( Table  2 ). Fatigue significantly correlated with the ESS and the OGS scores. A significant correlation was seen between the total COMPASS score and fatigue severity, as assessed using FIS ( Figure  3 ). Such a correlation further indicates the relevance of autonomic symptoms in VVS patients.

Table 2

Correlations between fatigue impact scale and the other symptom assessment tools in the vasovagal syncope group

FIS vs.
r
r2
P
ESS  0.5  0.2  <0.0001 
Orthostatic tolerance domain  0.5  0.22  <0.0001 
Vasomotor  0.3  0.10  0.003 
Secretomotor  0.5  0.25  <0.0001 
Gastrointestinal  0.4  0.14  0.0003 
Autonomic diarrhoea  0.3  0.09  0.005 
Constipation  0.3  0.08  0.009 
Bladder  0.2  0.06  0.03 
Pupils  0.4  0.17  <0.0001 
Sleep disorder  0.4  0.13  0.0008 
Syncope  0.4  0.13  0.0007 
Underscoring  −0.2  0.05  0.03 
Overscoring  0.4  0.13  0.0005 
Total  0.6  0.4  <0.0001 
FIS vs.
r
r2
P
ESS  0.5  0.2  <0.0001 
Orthostatic tolerance domain  0.5  0.22  <0.0001 
Vasomotor  0.3  0.10  0.003 
Secretomotor  0.5  0.25  <0.0001 
Gastrointestinal  0.4  0.14  0.0003 
Autonomic diarrhoea  0.3  0.09  0.005 
Constipation  0.3  0.08  0.009 
Bladder  0.2  0.06  0.03 
Pupils  0.4  0.17  <0.0001 
Sleep disorder  0.4  0.13  0.0008 
Syncope  0.4  0.13  0.0007 
Underscoring  −0.2  0.05  0.03 
Overscoring  0.4  0.13  0.0005 
Total  0.6  0.4  <0.0001 

Table 2

Correlations between fatigue impact scale and the other symptom assessment tools in the vasovagal syncope group

FIS vs.
r
r2
P
ESS  0.5  0.2  <0.0001 
Orthostatic tolerance domain  0.5  0.22  <0.0001 
Vasomotor  0.3  0.10  0.003 
Secretomotor  0.5  0.25  <0.0001 
Gastrointestinal  0.4  0.14  0.0003 
Autonomic diarrhoea  0.3  0.09  0.005 
Constipation  0.3  0.08  0.009 
Bladder  0.2  0.06  0.03 
Pupils  0.4  0.17  <0.0001 
Sleep disorder  0.4  0.13  0.0008 
Syncope  0.4  0.13  0.0007 
Underscoring  −0.2  0.05  0.03 
Overscoring  0.4  0.13  0.0005 
Total  0.6  0.4  <0.0001 
FIS vs.
r
r2
P
ESS  0.5  0.2  <0.0001 
Orthostatic tolerance domain  0.5  0.22  <0.0001 
Vasomotor  0.3  0.10  0.003 
Secretomotor  0.5  0.25  <0.0001 
Gastrointestinal  0.4  0.14  0.0003 
Autonomic diarrhoea  0.3  0.09  0.005 
Constipation  0.3  0.08  0.009 
Bladder  0.2  0.06  0.03 
Pupils  0.4  0.17  <0.0001 
Sleep disorder  0.4  0.13  0.0008 
Syncope  0.4  0.13  0.0007 
Underscoring  −0.2  0.05  0.03 
Overscoring  0.4  0.13  0.0005 
Total  0.6  0.4  <0.0001 

The prevalence of fatigue and its associations in those who continue to experience vasovagal syncope symptoms compared with those who have responded to treatment

The total VVS patient group was subdivided into those who had responded to treatment (i.e. were now asymptomatic) and those who had not (i.e. continued to experience the symptoms of VVS despite treatment). The two groups were then compared for each of the different questionnaire scores and the separate COMPASS domains. Fatigue and daytime sleepiness were significantly greater in the non-responding group when compared with the group where the treatment had been effective and symptoms were resolved ( Table  3 and Figure  4 ).

Figure 4

Fatigue impact scale scores for the non-responders, subdivided into those with syncope or pre-syncope.

Figure 4

Fatigue impact scale scores for the non-responders, subdivided into those with syncope or pre-syncope.

Table 3

Comparison in symptom assessment tools between responders to treatment and non-responders


Responders ( n = 44)
Non-responders ( n = 47)
P
FIS  44 ± 38  12 ± 14  <0.0001 
ESS  7.8 ± 4.9  5.6 ± 3.9  0.02 
Orthostatic tolerance  24 ± 8  8.8 ± 10  <0.0001 
Vasomotor  2.4 ± 2.7  0.5 ± 1.5  <0.0001 
Secretomotor  5.7 ± 4.8  3.4 ± 2.7  0.005 
Gastrointestinal  1.6 ± 2.2  0.6 ± 1.3  0.01 
Autonomic diarrhoea  3.2 ± 5.1  1.1 ± 2.5  0.02 
Constipation  2.0 ± 2.6  1.3 ± 2.4  0.2 
Bladder  2.0 ± 2.8  2.0 ± 2.8  1.0 
Pupils  0.9 ± 1.0  0.2 ± 0.5  <0.0001 
Sleep  2.0 ± 2.0  1.3 ± 1.8  0.07 
Syncope  3.6 ± 4.0  1.2 ± 2.5  0.001 
Underscoring  3.3 ± 3.8  4.7 ± 3.8  0.07 
Overscoring  0.6 ± 1.3  0.04 ± 0.3  0.007 
Total  47 ± 21  21 ± 14  <0.0001 

Responders ( n = 44)
Non-responders ( n = 47)
P
FIS  44 ± 38  12 ± 14  <0.0001 
ESS  7.8 ± 4.9  5.6 ± 3.9  0.02 
Orthostatic tolerance  24 ± 8  8.8 ± 10  <0.0001 
Vasomotor  2.4 ± 2.7  0.5 ± 1.5  <0.0001 
Secretomotor  5.7 ± 4.8  3.4 ± 2.7  0.005 
Gastrointestinal  1.6 ± 2.2  0.6 ± 1.3  0.01 
Autonomic diarrhoea  3.2 ± 5.1  1.1 ± 2.5  0.02 
Constipation  2.0 ± 2.6  1.3 ± 2.4  0.2 
Bladder  2.0 ± 2.8  2.0 ± 2.8  1.0 
Pupils  0.9 ± 1.0  0.2 ± 0.5  <0.0001 
Sleep  2.0 ± 2.0  1.3 ± 1.8  0.07 
Syncope  3.6 ± 4.0  1.2 ± 2.5  0.001 
Underscoring  3.3 ± 3.8  4.7 ± 3.8  0.07 
Overscoring  0.6 ± 1.3  0.04 ± 0.3  0.007 
Total  47 ± 21  21 ± 14  <0.0001 

Table 3

Comparison in symptom assessment tools between responders to treatment and non-responders


Responders ( n = 44)
Non-responders ( n = 47)
P
FIS  44 ± 38  12 ± 14  <0.0001 
ESS  7.8 ± 4.9  5.6 ± 3.9  0.02 
Orthostatic tolerance  24 ± 8  8.8 ± 10  <0.0001 
Vasomotor  2.4 ± 2.7  0.5 ± 1.5  <0.0001 
Secretomotor  5.7 ± 4.8  3.4 ± 2.7  0.005 
Gastrointestinal  1.6 ± 2.2  0.6 ± 1.3  0.01 
Autonomic diarrhoea  3.2 ± 5.1  1.1 ± 2.5  0.02 
Constipation  2.0 ± 2.6  1.3 ± 2.4  0.2 
Bladder  2.0 ± 2.8  2.0 ± 2.8  1.0 
Pupils  0.9 ± 1.0  0.2 ± 0.5  <0.0001 
Sleep  2.0 ± 2.0  1.3 ± 1.8  0.07 
Syncope  3.6 ± 4.0  1.2 ± 2.5  0.001 
Underscoring  3.3 ± 3.8  4.7 ± 3.8  0.07 
Overscoring  0.6 ± 1.3  0.04 ± 0.3  0.007 
Total  47 ± 21  21 ± 14  <0.0001 

Responders ( n = 44)
Non-responders ( n = 47)
P
FIS  44 ± 38  12 ± 14  <0.0001 
ESS  7.8 ± 4.9  5.6 ± 3.9  0.02 
Orthostatic tolerance  24 ± 8  8.8 ± 10  <0.0001 
Vasomotor  2.4 ± 2.7  0.5 ± 1.5  <0.0001 
Secretomotor  5.7 ± 4.8  3.4 ± 2.7  0.005 
Gastrointestinal  1.6 ± 2.2  0.6 ± 1.3  0.01 
Autonomic diarrhoea  3.2 ± 5.1  1.1 ± 2.5  0.02 
Constipation  2.0 ± 2.6  1.3 ± 2.4  0.2 
Bladder  2.0 ± 2.8  2.0 ± 2.8  1.0 
Pupils  0.9 ± 1.0  0.2 ± 0.5  <0.0001 
Sleep  2.0 ± 2.0  1.3 ± 1.8  0.07 
Syncope  3.6 ± 4.0  1.2 ± 2.5  0.001 
Underscoring  3.3 ± 3.8  4.7 ± 3.8  0.07 
Overscoring  0.6 ± 1.3  0.04 ± 0.3  0.007 
Total  47 ± 21  21 ± 14  <0.0001 

Non-responders reported significantly more autonomic symptoms than those who had responded to treatment, t (89) = 7.1; P = <0.0001 ( Table  3 ). A large significant difference was found between responders and non-responders, especially within the orthostatic tolerance, t (89) = 7.6; P = <0.001, and vasomotor domain of the COMPASS questionnaire, t (88) = 4.0; P = <0.001.

In order to determine the contribution of each symptomatic group to fatigue severity in VVS, each of the questionnaire and domain scores for the responder and non-responder groups were then correlated with the patients’ FIS. Table  4 reports the correlations for the non-responding to treatment group. None of the correlations for the responding group were significant. It is, therefore, only the results of the non-responder group that influence the overall relationship. The strength of the correlation between FIS scores and the ESS, OGS, and the total COMPASS score was equal for the non-responders ( Table  4 ).

Table 4

Correlation between fatigue impact scale scores and each of the other symptom assessment tools in the non-responders


r
r2
P
ESS  0.5  0.3  0.0002 
Orthostatic tolerance  0.3  0.1  0.04 
Vasomotor  0.1  0.01  0.5 
Secretomotor  0.5  0.2  0.001 
Gastrointestinal  0.4  0.1  0.001 
Autonomic diarrhoea  0.2  0.06  0.1 
Constipation  0.3  0.1  0.03 
Bladder  0.3  0.1  0.04 
Pupils  0.3  0.1  0.06 
Sleep  0.3  0.1  0.03 
Syncope  0.3  0.1  0.07 
Underscoring  −0.3  0.1  0.09 
Overscoring  0.3  0.1  0.08 
Total  0.5  0.3  0.0002 

r
r2
P
ESS  0.5  0.3  0.0002 
Orthostatic tolerance  0.3  0.1  0.04 
Vasomotor  0.1  0.01  0.5 
Secretomotor  0.5  0.2  0.001 
Gastrointestinal  0.4  0.1  0.001 
Autonomic diarrhoea  0.2  0.06  0.1 
Constipation  0.3  0.1  0.03 
Bladder  0.3  0.1  0.04 
Pupils  0.3  0.1  0.06 
Sleep  0.3  0.1  0.03 
Syncope  0.3  0.1  0.07 
Underscoring  −0.3  0.1  0.09 
Overscoring  0.3  0.1  0.08 
Total  0.5  0.3  0.0002 

Table 4

Correlation between fatigue impact scale scores and each of the other symptom assessment tools in the non-responders


r
r2
P
ESS  0.5  0.3  0.0002 
Orthostatic tolerance  0.3  0.1  0.04 
Vasomotor  0.1  0.01  0.5 
Secretomotor  0.5  0.2  0.001 
Gastrointestinal  0.4  0.1  0.001 
Autonomic diarrhoea  0.2  0.06  0.1 
Constipation  0.3  0.1  0.03 
Bladder  0.3  0.1  0.04 
Pupils  0.3  0.1  0.06 
Sleep  0.3  0.1  0.03 
Syncope  0.3  0.1  0.07 
Underscoring  −0.3  0.1  0.09 
Overscoring  0.3  0.1  0.08 
Total  0.5  0.3  0.0002 

r
r2
P
ESS  0.5  0.3  0.0002 
Orthostatic tolerance  0.3  0.1  0.04 
Vasomotor  0.1  0.01  0.5 
Secretomotor  0.5  0.2  0.001 
Gastrointestinal  0.4  0.1  0.001 
Autonomic diarrhoea  0.2  0.06  0.1 
Constipation  0.3  0.1  0.03 
Bladder  0.3  0.1  0.04 
Pupils  0.3  0.1  0.06 
Sleep  0.3  0.1  0.03 
Syncope  0.3  0.1  0.07 
Underscoring  −0.3  0.1  0.09 
Overscoring  0.3  0.1  0.08 
Total  0.5  0.3  0.0002 

The greater fatigue impact scores reported by the non-responders to the treatment correlated with an increased number of autonomic symptoms reported in the COMPASS questionnaire ( Figure  3 ). Those patients who had responded to the treatment tended to have lower FIS scores and subsequently fewer autonomic symptoms.

Determining whether syncope or pre-syncope contribute equally to the symptom burden in vasovagal syncope

In order to further explore the difference between the symptom burden in those with syncope and from those with pre-syncope, the non-responders to treatment were further divided into those who were currently suffering syncope (with or without pre-syncope) and those who suffered from pre-syncope alone. Syncope patients presented with slightly higher fatigue impact scores, however, the difference was not significant ( Figure  4 ).

Discussion

This study has confirmed that fatigue is a significant problem experienced by patients with VVS and as in other clinical situations, is associated with autonomic symptoms and excessive daytime sleepiness, and the severity of which correlates with fatigue severity. This study quantifies fatigue and other symptoms for the first time in VVS. The prevalence and severity of these symptoms suggest that VVS is a symptom complex that is not only associated with syncope but also with other symptoms that may arise due to similar or identical pathophysiology. These findings would support our hypothesis that the drop in blood pressure, which is the characteristic of VVS, not only impairs cerebral perfusion, leading to the symptom of syncope/pre-syncope, but may also affect perfusion of other organs, which manifest as the symptom of fatigue, and a wide range of other associated symptoms. The findings of this study are consistent with the previous studies. 7–9

This study has also highlighted a constellation of other previously largely unrecognized symptoms that appear to be associated with VVS. The high prevalence of symptoms consistent with autonomic dysfunction suggests that although the prognosis of VVS might be considered good in terms of the syncopal symptoms, there are a wide range of other symptoms that affect these patients. Importantly, the treatment appears to improve not only the syncopal symptoms but also the other associated symptoms, such as fatigue, and the array of autonomic symptoms seen in this study.

Vasovagal syncope patients scored higher than the control groups in each of the COMPASS questionnaire domains. In almost all the domains, VVS patients reported significantly more autonomic symptoms than the control group, with the exception of bladder, autonomic diarrhoea, and pupils. Although this is the first study to consider the symptoms of autonomic dysfunction in relation to VVS, our group has recently found that symptoms of autonomic dysfunction were strongly associated with CFS, and it is well recognized that neurally mediated hypotension is a frequent finding in those with CFS/myalgic encephalomyelitis (ME). 18 Interestingly, our recent CFS study revealed a total autonomic symptom burden only slightly greater than the symptom burden for VVS (43.7 ± 16.6 and 34.0 ± 23, respectively) with the most significant difference between controls and patients’ reported symptoms being within the orthostatic intolerance domain. This current study found a very similar profile of autonomic symptoms in VVS compared with that seen in the recent CFS study. This would support the hypothesis that the underlying biological processes that lead to both VVS and CFS may be similar which may provide important insights into the pathogenesis of fatigue, in general, and considering its prevalence (<2% of the UK population) and severity of CFS/ME, in particular.

This study was not designed to examine the direction of associations, therefore causation cannot be determined. However, the presence of fatigue and symptoms in VVS are important to consider when managing patients with VVS and as in endpoints in the context of clinical trials for VVS.

The strong associations seen in this study between COMPASS domain scores and excessive daytime sleepiness are consistent with the emerging evidence that autonomic dysfunction and daytime hypersomnolence are the significant contributors to the manifestation of the symptom of fatigue. 18 This study is the first to confirm in a syndrome associated with hypotension that the same is in fact true.

The finding of increased fatigue severity in those who continue to experience vasovagal symptoms would suggest that fatigue is not a disease-specific phenomenon in VVS but is in fact related to the physiological abnormalities that occur in these patients, i.e. when the underlying abnormalities are treated, the level of fatigue and its associates return to levels comparable with normal controls. This further reinforces the importance for clear, effective advice and treatment for those with VVS, and we would argue emphasizes the importance of making such a diagnosis conclusively. However, it is important to acknowledge that this needs to be tested both in a prospective, longitudinal study, and also taking into consideration the fluctuating symptoms that can be characteristic of the natural history of VVS.

The symptom of syncope is frequently considered more catastrophic than that of pre-syncope. However, the findings from our study suggest that both syncope and pre-syncope impact upon the quality of life of patients with VVS and that consideration of symptoms at both ends of the spectrum of VVS is important.

There are some limitations in this study. The primary methodological issue seems to be lower than the expected return rate. Only 65% of the patients responded to the questionnaires, despite the sending of a reminder, which may have been related to the number and length of the questionnaires. It could also be argued that symptomatic patients are more likely to respond to questionnaire-based studies, potentially introducing a degree of selection bias. This further reinforces the need to reproduce our findings in an independent cohort of patients where potential confounders such as the presence of depression and/or anxiety are also considered. The study was also a cross-sectional cohort study, and the VVS patients were not prospectively recruited. A further limitation is that VVS was not excluded (either clinically or by head up tilt) in the control group. This and the fact that VVS may develop during their lifetime is a potential confounder. Despite these limitations, we believe that this study raises important findings that will be explored in a prospective study.

In conclusion, fatigue appears to play an important role in the poor quality of life experienced by VVS patients. Patients suffer a higher than average amount of daytime sleepiness as well as a range of autonomic symptoms. These symptoms are especially profound in patients who have not responded to the conventional treatment. Such findings have implications for our understanding of the pathogenesis of fatigue and VVS, and how they are both treated in the future, as well as highlighting a need to examine patients presenting with CFS for signs of VVS.

Conflict of interest: none declared.

Funding

This study was supported by a grant from ME Research, UK.

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Fainting – NHS

Fainting is when you pass out for a short time. It is not usually a sign of something serious, but if it happens regularly you should see a GP.

Causes of fainting

There are many reasons why someone might faint. Causes include:

  • standing up too quickly – this could be a sign of low blood pressure
  • not eating or drinking enough
  • being too hot
  • being very upset, angry, or in severe pain
  • heart problems
  • taking drugs or drinking too much alcohol

Symptoms of fainting

Fainting usually happens suddenly. Symptoms can include:

  • dizziness
  • cold skin and sweating
  • slurred speech
  • feeling sick
  • changes to your vision

Non-urgent advice: See a GP if:

  • you have fainted and do not know the cause
  • you have recently fainted more than once

Information:

You must tell the Driver & Vehicle Licensing Agency (DVLA) if you’re fainting regularly as it could affect your ability to drive.

Find out how to tell the DVLA about fainting.

Things you can do to prevent fainting

If you feel like you are about to faint, try to:

  • lie down with your legs raised – if you cannot do this then sit with your head lowered between your knees
  • drink some water
  • eat something
  • take some deep breaths

If you see someone faint

If you are with someone who has fainted, try to keep calm.

If you can, lay them on their back and raise their legs.

Usually, the person who has fainted will wake up within 20 seconds.

Immediate action required: Call 999 if:

Someone faints and they:

  • cannot be woken up after 1 minute
  • have severely hurt themselves from a fall
  • are shaking or jerking because of a seizure or fit

Page last reviewed: 02 January 2020
Next review due: 02 January 2023

Faints (Vasovagal syncope)

What happens during fainting?

When you are upright, standing or sitting still, blood drops under the influence of gravity down into your legs. With more blood held in your legs, less blood returns to the heart, and the amount of blood the heart can pump around the body diminishes, and the blood pressure in the circulation will begin to drop.

Usually the body counteracts this and tries to maintain the blood pressure, by constricting  the blood vessels in the legs and abdomen, and by making the heart beat faster. In some people, these attempts to maintain the blood pressure are ineffective in the specific situations when the fainting reaction occurs

So when you begin to feel sweaty and faint this is because instead of constricting, some blood vessels get even wider (“vaso-dilate”), and the heart instead of speeding up may slow down or even stop momentarily. The result of this faulty response is that the heart cannot pump enough blood to the brain, and the lack of oxygen reaching the brain then makes you pass out. This is called Vasovagal syncope. (Syncope, pronounced sin-co-pee, is the greek / medical term for a blackout caused by not enough blood reaching the brain).

If you faint to the floor, or lie down before fainting (and if possible raise your legs), blood immediately returns to your heart, which can then pump blood to your brain again, and you regain consciousness. If you stay sitting up, your brain will remain starved of oxygen for longer, and during your faint you might even have jerky movements, that can be misinterpreted as a fit. Some people are incontinent during a profound faint. Again this is not evidence that the collapse was a fit.

Feeling ill and nauseous after a faint is very common, and is part of the digestive “vagal” activation, which often also makes you feel washed out for a time after a faint.

Why this fainting reaction happens more often to some people than to other is unknown. Some people seem to have more powerful “vagal” reactions in certain situations.

 

When does a fainting response occur?

Most people learn which circumstances might make them faint. People who are prone to fainting often develop symptoms in the following situations (which are all times when the vagal system is more active):

  • During emotional circumstances, or with medical/dental procedures.
  • When in pain (especially abdominal pain, or during a period).
  • During or directly after a meal, especially if you haven’t eaten for a while.
  • After a long period of standing still (in a queue or at a reception).
  • After sitting very still, especially then standing.
  • In warm surroundings (in a restaurant, warm weather, standing in a hot shower or sauna).
  • Directly after exercise.
  • When you have not had enough rest.
  • During illness, nausea or fever.

Symptoms of Vasovagal fainting

As the vasovagal fainting reaction begins, there is often light headedness, ringing in the ears, and feeling sweaty and nauseous. You may start yawning, and others may notice you have gone grey and sweaty. There is often a desire to get some fresh air (“air-hunger”), or to go urgently to the toilet (but standing up to go outside or to the toilet can then bring on the faint!).

As the blood pressure falls further, there is visual disturbance with black spots in front of the eyes, a feeling of becoming distant, and then one faints. People often recognise the symptoms, but sometimes the same people get very little warning and can pass out more suddenly.

During a faint, if someone feels your pulse it will usually be slow (during a seizure or fit it is usually fast). Some jerky movements may occur, especially if the person is still sitting or slouched with their head higher than their body.

When coming round after a faint, the person often feels awful, sickly and may vomit, or even have diarrhoea. Often there is prolonged fatigue after a faint.

Symptoms that are more worrying, and suggest the collapse may not be just a simple faint are:

  • Chest pain, severe breathlessness or severe headache before collapsing
  • Fitting with stiffness and/or jerky movements immediately on collapsing
  • Not breathing or going blue whilst unconscious
  • Prolonged unconsciousness, lasting more than 5-10 minutes once lying down.

IF IN DOUBT CALL 999 IMMEDIATELY AND CONSIDER STARTING BASIC LIFE SUPPORT.

 

Advice

Being susceptible to fainting is not a serious disease, but can be very frightening and frustrating to you and those around you. With advice and understanding of the problem, most people can avoid or minimise most faints. Worrying will only tend to make it worse.

It is important to understand what is happening to you during a faint. Ask your doctor for more explanation if you don’t fully understand what fainting is or if you have any more questions. Also, explain your faints to your family, so they can help and support you.

Try to work out in which particular set of circumstances you are most likely to faint Then try to avoid these sets of circumstances (eg stressed, long day, little food or drink, then out late to hot restaurant, beginning to relax, food arrives…)

When standing still (eg in queues), move up and down on the balls of your feet, so your calf muscles squeeze blood back up to your heart, or stand cross-legged (so you use more muscles to stay up, and stimulate your sympathetic system to keep up your blood pressure).

When standing or sitting still, occasionally clench tightly your thigh and buttock muscles for 10-15 seconds (this also keeps your sympathetic system active).

Try to wear elasticated support socks (“Flight Socks”) to prevent pooling of blood in the legs.

Ensure you drink enough fluids (tea, coffee and alcohol don’t count), especially on hot days, or if you have been exercising or have had diarrhoea or vomiting. Your urine should be clear. Avoid alcohol if you are hot – both heat and alcohol relax your blood vessels, lowering your blood pressure.

”Isotonic” fluids can be especially helpful – these are “sports” drinks that contain some salt and minerals, to help keep your circulation properly hydrated.  But avoid the ones with caffeine.

Avoid large meals on an empty stomach.

If you recognise the start of any symptoms of the fainting reaction, try to lie down immediately, ideally with your legs elevated. Sitting bent forward with your head down between your legs may help, but is not ideal as your legs remain down, and though abdominal compression might help, it might also worsen the vagal reaction, prolong your symptoms and delay recovery.

Remember, it is better to decide to lie down and remain conscious, than to pass out and wake up on the floor in a mess, surrounded by anxious onlookers.

Once you begin to feel faint, do not stand up quickly, or stand still (eg outside for fresh air)

If you faint, do not try to sit up or get up quickly when you come round – you may faint again!

 

Further reading:

Low blood pressure – on the British Heart Foundation website

 

Definition, Symptoms, Causes & Possible Treatments

There are several different types and subtypes of syncope.

Neurally mediated, or reflex syncope

Reflex syncope is the most common type. It occurs when a reflex response causes blood vessels to dilate and the heart rate to slow, leading to low blood pressure and decreased blood flow to the brain. Young adults are most likely to have this type of syncope.

There are three types of reflex syncope:

  • Vasovagal, which is the most common of all types of fainting. Vasovagal syncope occurs when the vagus nerve triggers a sudden decrease in blood pressure and heart rate. Common stimuli include heat exposure, emotional stress, fear, distress, and events that can potentially or actually cause pain.
  • Situational, which is similar to vasovagal, but only occurs during certain actions or situations. This includes coughing, urinating, after eating, after exercising, or upon sudden startling or pain.
  • Carotid sinus syndrome, which is the least common reflex syncope. It occurs when there is too much pressure on the carotid arteries in your neck. These arteries carry oxygen-rich blood to your brain. Common triggers include rotating your head too quickly or too much, wearing a tight collar, and shaving.

Cardiac syncope is related to problems with the heart. It is the second most common type of syncope after reflex syncope. Fainting is the result of the heart not being able to pump out enough blood. Most cases of cardiac syncope are due to arrhythmias. Structural and mechanical heart problems can also cause it. Older adults are more likely to suffer with cardiac syncope. However, cardiac syncope due to arrhythmia is often the cause of sudden death in young adults.

Neurologic syncope is the result of a neurologic or cerebrovascular condition. This includes seizures, stroke, TIA (transient ischemic attack), basilar artery disease, and even migraine.

Orthostatic or postural syncope

Postural syncope occurs when you change positions and blood pressure drops too quickly. This can happen with dehydration, blood loss, low blood sugar, and several other diseases, disorders and conditions. Certain medications can also cause it, such as blood pressure, allergy, and diabetes medications.

Psychogenic syncope occurs with mental health disorders, such as depression, anxiety disorders, and panic disorders.

POTS (Postural Orthostatic Tachycardia Syndrome)

POTS is a rare disorder that tends to affect women more than men. It occurs when the heart rate goes very high after a person rises from a sitting or lying down position. The very rapid heart rate interferes with the heart’s ability to pump out enough blood.

Unfortunately, the cause of syncope is unknown in up to a third of cases.

Feeling lightheaded and dizzy can be signs of a potentially life-threatening condition, such as a heart attack, stroke, or shock (a severe blood pressure drop). Seek immediate medical care (call 911) if you experience dizziness with feelings of pain or pressure in your chest, speech problems, shortness of breath, sudden weakness or numbness on one side of the body, chest pain that radiates down the arm or to the jaw, or alterations in vision.

Chronic Fatigue Syndrome (for Parents)

What Is Chronic Fatigue Syndrome?

Chronic fatigue syndrome (CFS) is a complicated disease for doctors to diagnose — and even fully understand.

CFS is a physical condition, but it can also affect a person emotionally. This means that someone with CFS may feel physical symptoms, such as:

  • extreme fatigue (a feeling of being very tired and weak)
  • headaches
  • dizziness

But the person may also notice emotional symptoms, such as a loss of interest in favorite activities.

Also, different people with CFS can have different symptoms. Many CFS symptoms are similar to those of other health conditions, like mono, Lyme disease, or depression. And the symptoms can vary over time, even in the same person.

This makes treating the illness complicated. No single medicine or treatment can address all the possible symptoms.

What Are the Signs & Symptoms of Chronic Fatigue Syndrome?

There’s a long list of possible symptoms that someone with

chronicfatigue syndrome can have. The most common ones include:

  • severe fatigue, which can make it hard to get out of bed and do normal daily activities
  • sleep problems, such as trouble falling or staying asleep, or not having a refreshing sleep
  • symptoms getting worse after physical or mental effort (this is called post-exertional malaise)
  • symptoms or dizziness that get worse after standing up or sitting upright from a lying down position
  • problems with concentration and memory
  • headaches and stomachaches

What Causes Chronic Fatigue Syndrome?

Scientists have been researching chronic fatigue syndrome for many years, but they still aren’t sure what causes it.

Many doctors believe that the way some conditions interact in the body and mind might leave some people at risk for CFS. For example, if someone has a

virusand is under a lot of stress, this combination might make them more likely to develop CFS.

Experts think that these things interact this way, putting some people at risk for chronic fatigue syndrome:

  • infections. Experts have wondered if infections like measles or Epstein-Barr virus (the virus that causes mono) might increase the risk for CFS. The role Epstein-Barr plays in CFS is not clear because studies have not confirmed it as a cause.
  • problems with the immune system or the nervous system
  • hormone imbalances
  • emotional stress
  • low blood pressure

Who Gets Chronic Fatigue Syndrome?

Chronic fatigue syndrome can affect people of all ethnicities and ages, but is most common in people in their forties or fifties. It’s very rare in kids. A few teens do get CFS, and it affects more girls than guys.

Sometimes different people in the same family get CFS. This may be because the tendency to develop CFS is genetic.

How Is Chronic Fatigue Syndrome Diagnosed?

Right now, there’s no test to tell if someone has chronic fatigue syndrome. Doctors ask a lot of questions about things like:

  • a person’s
    medical history and the health of family members
  • medicines taken
  • allergies
  • smoking and drinking habits

They also will do an exam.

Doctors also usually order blood, urine (pee), or other tests to check for conditions that cause similar symptoms. They may send a person to see other specialists, such as a sleep specialist or a neurologist, to help with the diagnosis.

The doctor may suggest meeting with a psychologist or a therapist to see whether mental health disorders might contribute to or mask CFS.

Because kids and teens often feel tired for many reasons, CFS can be a misused or abused diagnosis. Kids sometimes use being tired as a way to avoid school or other activities. Many teens are active in different sports, which can make them tired. For these reasons, doctors are careful when making a diagnosis of CFS.

How Is Chronic Fatigue Syndrome Treated?

There’s no known cure for chronic fatigue syndrome. But experts say that these lifestyle changes can help kids and teens who have it:

  • Regular planned exercise as part of a daily routine. Exercise can increase energy and make a person feel better. Teens with CFS should pace themselves while doing any physical activity that takes a lot of effort. Several studies show that “graded exercise” is very helpful in CFS recovery. This means starting with small activities and slowly working up to a higher level of exercise.
  • Follow stress-management and stress-reduction techniques. A doctor or therapist can teach teens great ways to take control of some aspects of the illness.
  • Ensure good sleep habits and regular bedtime routines to overcome CFS-related sleep problems.
  • Find ways to keep track of important things, such as keeping lists and making notes, if there are problems with concentration or memory.

Meeting often with a therapist or counselor can help in CFS treatment. So can getting involved in a support group for people with CFS. The main goals of therapy are:

  • to help people cope with the illness
  • to change negative or unrealistic thoughts or feelings into positive, realistic ones

Having a positive outlook about getting better is very helpful. Therapy and support groups can also help students with CFS deal with the academic or social challenges. It’s common for kids and teens with CFS to miss school, have poor grades, or withdraw from friends and social situations.

Doctors may suggest over-the-counter or prescription medicines for some of these symptoms.

How Can I Help My Child?

To help your child cope with the emotional symptoms of chronic fatigue syndrome:

  • Encourage your child to keep a daily diary to identify times when he or she has the most energy and help plan activities for these times.
  • Have your doctor plan an exercise program to maintain strength at whatever level is possible. This can help your child feel better physically and emotionally.
  • Help your child to recognize and express feelings, such as sadness, anger, and frustration. It’s OK to grieve the loss of energy.
  • Get support from family and friends because emotional health is important when coping with a chronic health problem.
  • Allow more time for your child to do things, especially activities that take concentration or physical exertion.

What Can I Expect?

Having chronic fatigue syndrome can be hard. But for most people, the symptoms are most severe in the beginning. Later, they may come and go. Teens with CFS generally get better faster and recover more completely than adults do. Most teens get partial or full recovery within 5 years after symptoms began.

Many new and experimental treatments for CFS are available. But don’t use any unproven treatments (such as extreme doses of vitamin or herbal supplements) until checking with your doctor.

CFS is a misunderstood illness. But scientists continue to learn about it through research and clinical trials. They’re trying to better understand its symptoms and causes in kids and teens.

Good medical care and coping techniques are the keys to helping your child manage chronic fatigue syndrome. It can also help to find support sites and groups, such as:

Vasovagal Syncope | Cedars-Sinai

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What is vasovagal syncope?

Vasovagal syncope is a condition
that leads to fainting in some people. It is also called neurocardiogenic syncope or
reflex syncope. It’s the most common cause of fainting. It’s usually not harmful nor a
sign of a more serious problem.

Many nerves connect with your heart
and blood vessels. These nerves help control the speed and force of your heartbeat. They
also regulate blood pressure by controlling whether your blood vessels widen or tighten.
Usually, these nerves coordinate their actions so you always get enough blood to your
brain. Under certain situations, these nerves might give an inappropriate signal. This
might cause your blood vessels to open wide. At the same time, your heartbeat may slow
down. Blood can pool in your legs which leads to a drop in blood pressure, and not
enough of it may reach the brain. If that happens, you may briefly lose consciousness.
When you lie or fall down, blood flow to the brain resumes.

Vasovagal syncope is quite common. It most often affects children and young adults, but it can happen at any age. It happens to men and women in about equal numbers. Unlike some other causes of fainting, vasovagal syncope does not signal an underlying problem with the heart or brain.

What causes vasovagal syncope?

Several triggers can cause
vasovagal syncope. To help reduce the risk of fainting, you can stay away from some of
these triggers such as:

  • Standing for long periods
  • Excess heat
  • Intense emotion, such as fear
  • Intense pain
  • The sight of blood or a needle
  • Prolonged exercise
  • Dehydration
  • Skipping meals

Other triggers include:

  • Urinating
  • Swallowing
  • Coughing
  • Having a bowel movement

What are the symptoms of vasovagal syncope?

Fainting is the defining symptom of vasovagal syncope. Often you may have certain symptoms before actually fainting such as: 

  • Nausea
  • Warmth
  • Turning pale
  • Getting sweaty palms
  • Feeling dizzy or lightheaded
  • Blurred vision

If you can lie down at the first sign of these symptoms, you will often be able to prevent fainting. When it happens, this type of fainting almost always happens in a sitting or standing position. Not everyone notices symptoms before fainting, however.

When a person does faint, lying down restores blood flow to the brain. Consciousness should return fairly quickly. You might not feel normal for a little while after you faint. You might feel depressed or fatigued for a short time. Some people even feel nauseous and may vomit.

Some people have only 1 or 2 episodes of vasovagal syncope in their life. For others, the problem is more chronic and happens with no warning.

How is vasovagal syncope diagnosed?

Your doctor will review your
medical history and do a physical exam. This will probably include measuring the blood
pressure while lying down, seated, and then standing. Your doctor will likely do an
electrocardiogram (ECG) as well, to evaluate the heart’s rhythm. For many children and
young adults, this may be all that is needed. Usually, the doctor can safely assume that
the fainting is due to vasovagal syncope, and not some form of syncope that is more
dangerous.

Sometimes the doctor needs to check
for other possible causes for fainting. Because some causes of fainting are dangerous,
the doctor will want to rule out these other causes. Your doctor might use tests such as
the following:

  • Continuous portable ECG monitoring, to
    further analyze heart rhythms
  • Echocardiogram, to examine blood flow
    in the heart and heart motion
  • Exercise stress testing, to see how
    your heart works during exercise
  • Blood work, only if your doctor is
    suspicious for an abnormality

If these tests are normal, you
might need something called a “tilt table test.” For this test, you lie down on a padded
table. Someone measures your heart rate and blood pressure while you are lying down and
then tilted up for a period of time. Sometime medicine is also given to trigger a
fainting response. If you have vasovagal syncope, you may faint during the upward
tilt.

How is vasovagal syncope treated?

Watch for the warning signs of
vasovagal syncope, like dizziness, nausea, or sweaty palms. If you have a history of
vasovagal syncope and think you are about to faint, lie down right away. Tensing your
arms or crossing your legs can help prevent fainting. Passively raising or propping up
your legs in the air can also help.

To immediately treat someone who has fainted from vasovagal syncope, help the person lie down and lift his or her legs up in the air. This will restore blood flow to the brain, and the person should quickly regain consciousness. The person should lie down for a little while afterwards.

If you have had episodes of vasovagal syncope, your doctor might make some suggestions on how to help prevent fainting. These might include:

  • Avoiding triggers, such as standing
    for a long time or the sight of blood
  • Moderate exercise training
  • Discontinuing medicines that lower
    blood pressure, like diuretics
  • Eating a higher salt diet, to help
    keep up blood volume
  • Drinking plenty of fluids, to maintain
    blood volume
  • Wearing compression stockings or abdominal binders

Occasionally, you may need medicine to help control vasovagal syncope. However, research on these medicines has revealed uncertain benefits in vasovagal syncope. These are usually only considered when a person has multiple episodes of fainting. Some of the medicines your doctor may advise a trial of include:

  • Alpha-1-adrenergic agonists, to increase blood pressure
  • Corticosteroids, to help increase the sodium and fluid levels
  • Serotonin reuptake inhibitors (SSRIs), to moderate the nervous system response

If these medicines are ineffective,
doctors sometimes try orthostatic training. This method uses a tilt table to gradually
increase the amount of time spent upright. Rarely, in cases where a significant slowing
of the heartbeat or pausing is detected, a heart pacemaker is needed.

What are possible complications of vasovagal syncope?

Vasovagal syncope itself is generally not dangerous. Of course, fainting can be dangerous if it happens at certain times, like while driving. Most people with rare episodes of vasovagal syncope can drive safely. If you have chronic syncope that is not under control, your doctor may advise against driving. This is especially likely if you don’t usually have warning signs before you faint. Ask your doctor about what is safe for you to do.

When should I call my healthcare provider?

See a doctor right away if you have recurrent episodes of passing out or other related problems.

Key points about vasovagal syncope

  • Vasovagal syncope is the most common cause of fainting. It happens when the blood
    vessels open too wide and/or the heartbeat slows, causing a temporary lack of blood
    flow to the brain.
  • It’s generally not a dangerous
    condition.
  • To prevent fainting, stay out of hot
    places and don’t stand for long periods.
  • If you feel lightheaded, nauseous, or
    sweaty, lie down right away and raise your legs.
  • Most people with occasional vasovagal
    syncope need to make only lifestyle changes such as drinking more fluids and eating
    more salt.
  • Some people may need medicine or even
    a heart pacemaker.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

  • Know the reason for your visit and what you want to happen.
  • Before your visit, write down questions you want answered.
  • Bring someone with you to help you ask questions and remember what your provider tells you.
  • At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
  • Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
  • Ask if your condition can be treated in other ways.
  • Know why a test or procedure is recommended and what the results could mean.
  • Know what to expect if you do not take the medicine or have the test or procedure.
  • If you have a follow-up appointment, write down the date, time, and purpose for that visit.
  • Know how you can contact your provider if you have questions.

Medical Reviewer: Steven Kang MD

Medical Reviewer: Quinn Goeringer PA-C

Medical Reviewer: Lu Cunningham

© 2000-2021 The StayWell Company, LLC. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional’s instructions.

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Fainting

Fainting is characterized by sudden loss of consciousness. This is due to the slowed down blood flow in the brain.

The causes of fainting can be a sharp drop in blood pressure, as a result of which the body cannot get used to such changes.

With some heart diseases, during intense physical activity, when the pressure drops sharply, and the heart cannot increase the release of blood.

Fainting, can occur with a large loss of blood, with severe diarrhea, when the body is dehydrated.

Fainting occurs in various emotional states. This is a fear of blood, some kind of strong nervous tension.

Some diseases are the cause of this condition, this is diabetes mellitus, respiratory and kidney diseases, low hemoglobin.

The symptoms of this condition boil down to the fact that, first of all, before losing consciousness, a person feels an attack of lightheadedness, tinnitus, darkening in the eyes, and slight nausea occurs.A person’s legs begin to give way, and he faints.

The skin becomes pale, in rare cases, a slight blush on the cheeks may persist, the unconscious person is covered with cold sweat. The pulse rate becomes rare, blood pressure drops sharply. Pupils with fainting are dilated and do not respond well to light.

Fainting usually lasts for a few seconds. Loss of consciousness that lasts up to five minutes can lead to seizures and lead to involuntary urination.

After the end of the fainting spell, a person feels tired, he wants to sleep or at least lie down.

Emergency care during fainting is to lay the person down with the legs in an elevated position. Bring a cotton ball moistened with a solution of ammonia under the nose. Sprinkle cold water on the patient’s face, unfasten the pressing clothes. If a person is in a stuffy room, open the windows.

To increase the pressure, the unconscious can be given a solution of caffeine.

If fainting occurs repeatedly, then such a person must be examined and their cause established. Sometimes loss of consciousness can accompany a disease such as epilepsy.

Prevention of fainting is reduced to the elimination of factors that can lead to fainting, especially for patients with certain chronic diseases.

Fainting

Back

Fainting is a short-term loss of consciousness resulting from transient cerebral ischemia and usually leading to a person’s fall.

Fainting is a brief loss of consciousness resulting from decreased blood supply to the brain and usually leading to a fall.

Fainting states (syncope) can be divided into three large groups:

  1. Noncardiogenic syncope – not associated with heart disease;
  2. Cardiogenic syncope – due to heart disease;
  3. Fainting with unknown cause.

It is very important to determine the cause of loss of consciousness, since the prognosis of life depends on it.

Frequency of development and mortality in fainting, depending on the category

Category Frequency% Mortality during the year
Noncardiogenic 76 0-12
Cardiogenic 19 20-30
With unknown cause 5 6

Noncardiogenic syncope

This is a large group of diseases that are not associated with heart disease and have a relatively favorable prognosis …Among them, the following are most often distinguished:

  • Vasovagal syncope – common at a young age, often family in nature, developing on stress, trauma, sudden pain, the sight of blood or an unpleasant environment. In this case, excessive activation of cardiovascular reflexes occurs, which leads to vasodilation and a decrease in the pulse rate, to a decrease in blood pressure and a decrease in the blood supply to the brain. These syncope usually develop in an upright position, preceded by the appearance of pallor, sweating, nausea, and “fog before eyes”.

  • Orthostatic syncope – occurs due to a drop in blood pressure, when the body position changes from horizontal to vertical. This is often observed with a decrease in the volume of circulating blood (blood loss, vomiting, diarrhea), with vasodilatation against the background of taking medications (nitrates, diuretics, antidepressants, urological drugs, etc.), with pathology of the autonomic nervous system (diabetes mellitus, Parkinson’s disease, chronic renal failure, etc.).
  • Fainting with lesions of the cerebral vessels – is a complication of lowering blood pressure in older age groups with atherosclerotic lesions of the vessels of the head. Sometimes fainting can be the initial manifestation of a stroke.
  • Fainting in atherosclerosis of the subclavian artery – occurs with its atherosclerotic lesion to the point of origin of the vertebral artery. This condition is manifested by the difference in blood pressure on the hands (more than 10 mm Hg), the occurrence of loss of consciousness while working with the hand.The most accurate method for diagnosing this syncope is – ultrasound of the vessels of the neck and head;
  • Fainting with damage to the carotid sinus – occurs with an increase in the sensitivity of the receptors of the vessels of the neck. Loss of consciousness is triggered by turning the head, shaving, or wearing a tight collar. In many cases, there is a background violation of the conduction of the heart, which is detected when recording an ECG or conducting daily monitoring of an ECG.

To make a diagnosis, a diagnostic test is carried out – massage of the carotid sinus for 2-4 seconds with simultaneous recording of an ECG.

  • Situational fainting – manifested when coughing, after eating, while urinating or defecating. There may also be various neuropsychiatric causes, which a doctor will help to sort out.

Cardiogenic syncope

These syncope develops when there is an obstruction of the release of blood from the heart into the vessels or disturbances in the rhythm and conduction of the heart, which lead to a significant decrease in blood supply to the brain and loss of consciousness.With these faints, there is a high frequency of sudden death, therefore, to establish the cause of this condition is the most important task of a cardiologist.

  • Fainting due to obstruction of cardiac output – damage to the aortic valve (aortic stenosis), damage to the mitral valve (mitral stenosis), hypertrophic cardiomyopathy, atrial tumor (myxoma), pericardial disease (outer lining of the heart), pulmonary embolism, congenital heart defects.These states are established during an ECHO-cardiographic study.
  • Fainting caused by disturbed heart rhythm and conduction – with sick sinus syndrome, AV block, paroxysmal supraventricular and ventricular tachycardias, WPW syndrome and long QT syndrome, proarrhythmogenic effect of drugs, disruption of the pacemaker, which are established when registering an ECG or conducting daily monitoring of an ECG.

Fainting with unknown cause

This group includes patients in whom, after a comprehensive examination, the cause of loss of consciousness remains unclear. In this case, further observation and re-examination are required due to the increased risk of death in these patients, which is probably due to the presence of persons with unknown heart diseases among them.

Diagnostic methods for fainting

  1. ECG registration is a simple and informative method for diagnosing cardiogenic syncope, which allows at the initial stage to suspect ischemic or arrhythmic syncope genesis (myocardial ischemia, pathological Q waves, AV block, sinus 40 beats / min, alternating bundle branch blockade, paroxysms of tachycardia, disruption of the pacemaker).
  2. Orthostatic test – performed by a cardiologist and confirmed by the appearance of hypotension during the test. In this case, the patient, after staying for 5 minutes in a horizontal position, is measured by blood pressure, and then in a standing position.
  3. Echocardiography is a method that allows you to clarify the diagnosis of cardiogenic syncope, even if no pathology was detected by previous methods (aortic stenosis, atrial septal aneurysm, heart tumors, non-compact myocardium, etc.)NS.).
  4. Daily ECG monitoring – is of great informative value, especially in case of frequently recurring disturbances of consciousness. Allows you to assess the dynamics of the rhythm and conductance during the day, to identify the relationship of patient complaints with changes in the ECG.
  5. Carotid sinus massage and ECG registration – massage of the reflexogenic zone on the neck is performed with simultaneous ECG registration. The test is positive in the presence of cardiac arrest (asystole) for more than 3.0 seconds and a decrease in blood pressure of more than 50 mm Hg.
  6. Tilt test – performed on a special table that allows you to change the angle of inclination of the patient’s position. In this case, the patient’s hemodynamic parameters are assessed and an ECG is recorded.

Treatment of syncope

Treatment of syncope should have a differential approach depending on the cause of their occurrence. Special attention should be paid to cardiogenic syncope. The treatment is selected by the doctor individually for each patient after the minimum necessary examination.

For example, in case of reflex fainting, first of all, non-drug prevention methods are recommended (avoid provoking factors, take a horizontal position when pre-fainting symptoms appear, etc.). In carotid sinus syndrome, most studies have shown benefits of dual-chamber pacemaker implantation.

In case of orthostatic syncope, drugs that provoke hypotension and vasodilation are excluded, alcohol intake is excluded, salt intake is increased in the absence of hypertension, etc.Patients with cardiogenic syncope are treated with antiarrhythmic therapy, surgical treatment, or implantation of a pacemaker with defibrillation function.

Thus, do not underestimate such a common symptom as fainting, because it can be the first sign of serious heart disease!

Diagnostics – Fainting (syncope) – Urgent conditions in neurology – Directory of nosologies – List of nosologies

Careful collection of anamnesis of the disease and examination of the patient are the most specific methods for diagnosing fainting [1], the diagnosis can be made in 50–85% of patients.No laboratory test is more diagnostic. The medical history and examination of the patient along with the 12-lead ECG were noted as the 2007 American Society of Emergency Physicians (ACEP) Level A recommendations for syncope [2].

A detailed episode report should be received from the patient, including the following:

  • Provoking factors
  • Activities the patient was involved in prior to the event
  • Position the patient was in during the event

Triggers may include: fatigue, sleep or food deprivation, hot rooms, alcohol consumption, pain, and intense emotions.It is necessary to clarify the type of physical activity before syncope develops. Fainting may occur: at rest; when changing posture; with physical exertion; after physical exertion; in certain situations, such as shaving, coughing, emptying, or standing upright for a long time. Fainting that occurs within 2 minutes after a change in body position indicates orthostatic hypotension [28]. Fainting while sitting or lying down is most likely cardiac [29].Patients with true fainting do not remember the moment they fell to the ground.

The following clarifying questions should be asked:

  • Was the loss of consciousness complete?
  • Was the loss of consciousness quick and short-lived?
  • Was the recovery of consciousness spontaneous, complete and without consequences?
  • Has postural tone been lost?

If the answer is yes, fainting is very likely; if 1 or more is negative, other types of loss of consciousness should be considered [3].

Lightheadedness may be as follows: dizziness; weakness, profuse sweating, epigastric discomfort, nausea, blurred vision, pallor, paresthesia.

Symptoms that should be treated with increased attention: a sharp decrease in physical activity, chest pain, shortness of breath, back pain, heart palpitations, severe headache, focal neurological symptoms, diplopia, ataxia, dysarthria.

Other information to be obtained includes the following:

  • Detailed episode report from any available witnesses
  • Patient history
  • History of existing heart disease

The duration of symptoms preceding syncope is, on average, up to 2.5 minutes for vasovagal syncope, and about 3 seconds for syncope associated with arrhythmia.Patients should be asked to rate the duration of the loss of consciousness. Seizure activity may indicate an epileptic seizure. A history should be taken from all patients with syncope, with particular emphasis on the use of cardiac and antihypertensive drugs.

A complete physical examination is required, with particular attention to the following:

  • Vital Signs Analysis
  • Capillary blood glucose measurement
  • Detailed examination of the cardiovascular and respiratory systems
  • Detailed neurological examination
  • Assessment of signs of trauma

A complete physical examination is required for all patients admitted to the emergency department.Particular attention should be paid to some aspects of the physical examination in patients with syncope.

It is always necessary to analyze vital signs. Fever can indicate a cause of fainting, such as an infection. Postural changes in blood pressure and heart rate may indicate an orthostatic cause of syncope, but is generally unreliable. Tachycardia can be an indicator of pulmonary embolism, hypovolemia, tachyarrhythmia, or acute coronary syndrome. Bradycardia may indicate a vasodepressor cause of syncope, cardiac conduction disorder, or acute coronary syndrome.

Glucose should be assessed in every patient with syncope. Hypoglycemia can give a clinical picture identical to syncope.

A detailed cardiological examination is required. Irregular rhythm, bradyarrhythmia, and tachyarrhythmia must be diagnosed. Auscultation of heart sounds can reveal murmurs indicating valvular defects. A search for objective signs of congestive heart failure is carried out, including swelling of the jugular veins, wheezing in the lungs, hepatomegaly, edema.The abdominal wall should be examined and palpated for a pulsating abdominal aorta.

A detailed neurological examination helps to establish the initial state, as well as to identify new or growing neurological deficits. Patients with syncope should be of normal mental status. Confusion, headache, and doubtfulness cannot be attributed to syncope, and these symptoms may be the result of toxic, metabolic, or other damage to the central nervous system.

The patient should be examined for signs of injury. Injury can be sustained after fainting. In some cases, previous head trauma results in loss of consciousness. Tongue bite is considered specific for seizures.

Massage of the carotid sinus has been used to diagnose syncope of this genesis, but can cause prolonged pauses in heart contractions and hypotension.

Laboratory examination of patients

No laboratory test is specific or complete for the assessment of syncope.Recommendations for diagnosis:

  • General clinical blood test
  • Serum glucose test
  • Serum electrolyte analysis
  • General clinical analysis of urine

Research that may also be useful:

  • Chest X-ray – useful for detecting pneumonia, congestive heart failure, pulmonary edema, effusion, or dilated mediastinum
  • Computed tomography (CT) of the brain – has low diagnostic value in fainting, but may be clinically indicated in patients with neurological deficits or in patients with head trauma after fainting
  • CT of the chest and abdomen – indicated only in selected cases, for example, if there is a suspicion of aortic dissection, rupture of an abdominal aortic aneurysm, or pulmonary embolism (PE)
  • Magnetic resonance imaging (MRI) of the brain and magnetic resonance arteriography (MRA) – may be required in some cases to assess the vertebrobasilar vasculature
  • Perfusion lung scintigraphy – indicated for patients with suspected pulmonary embolism
  • Echocardiography – a test to assess functional disorders of the heart, valvular pathology as causes of fainting

The standard 12-lead ECG is a Level A recommendation (in the 2007 ACEP syncope guidelines) [2].Normal ECG results are a good prognostic sign. An ECG can be useful in diagnosing acute infarction or myocardial ischemia, and in detecting cardiac arrhythmias. Bradycardia, pauses, unstable ventricular tachycardia, persistent ventricular tachycardia, and atrioventricular conduction abnormalities can only be diagnosed by comparing the clinical picture with the results of a 12-lead ECG. Cardiomonitoring has no less high diagnostic accuracy than Holter monitoring; outpatient examination has a negative rather than positive diagnostic value [4,5].

Other diagnostic tests and procedures:

  • Orthostatic test – useful for confirming autonomic dysfunction and can usually be done on an ambulatory basis
  • Electroencephalography (EEG) – applicable for differential diagnosis of loss of consciousness of epileptic genesis
  • Stress test – suitable for patients with suspected cardiogenic syncope and who have risk factors for coronary atherosclerosis
  • Massage of the carotid sinus (for the diagnosis of carotid syncope)

A variety of diseases can mimic fainting.Central nervous system involvement, such as a hemorrhage or seizure, may resemble fainting. Fainting may not be caused by decreased cerebral blood flow in patients with severe metabolic disorders (eg, hypoglycemia, hyponatremia, hypoxemia).

Life-threatening conditions that cause syncope to be considered and diagnosed:

  • Dehydration
  • Diabetic neuropathy
  • Medical orthostasis
  • Ectopic pregnancy
  • Bleeding
  • Hypotension
  • Hypovolemia
  • Multisystem atrophy
  • Peripheral polyneuropathy
  • Postural hypotension
  • Subclavian steal
  • Vasomotor insufficiency
  • Bradydysarrhythmias
  • Heart mixoma
  • Obstruction of outflow from the heart
  • Hypertrophic subaortic stenosis
  • Paroxysmal supraventricular tachycardia
  • Paroxysmal ventricular tachycardia
  • Primary pulmonary hypertension
  • Long QT syndrome
  • Sick sinus syndrome
  • Sinoatrial unit
  • Pauses (> 3 seconds)
  • Tachyarrhythmias
  • Tricuspid stenosis

Situational conditions to consider in patients with suspected syncope include the following:

  • Carotid sinus syncope
  • Fainting cough (post-cough)
  • Fainting bowel movements
  • Urinary syncope
  • Fainting after eating
  • Fainting swallowing

Metabolic / endocrine conditions in patients with suspected syncope:

  • Hypothyroidism
  • Hypoxemia
  • Pheochromocytoma

Central nervous system disorders that should be considered in patients with suspected syncope include the following:

  • Hyperventilation Syndrome
  • Hydrocephalus
  • Migraine
  • Narcolepsy
  • Panic attacks
  • Epileptic seizures

90,000 reasons, treatment.When to see a doctor?

Fainting, or syncope – syncope, comes from the Greek word syncope, which means “off” or “interrupt.”

Physicians dealing with syncope always fear that the syncope may actually be interrupted by an episode of sudden death. The first to notice the ambiguity of fainting was Hippocrates. In his treatises, he points out that, according to his observations, patients who suffered from fainting died for no apparent reason.

Fainting is a spontaneous loss of consciousness with a rapid onset associated with insufficient blood supply to the brain (for a number of reasons).

The incidence of syncope varies for different age groups. Peaks occur at the age of 2 decades of life (adolescents, more often girls than boys) and over 60 years of age. As a rule, at a young age, vaso-vagal syncope predominates, but in any case, dangerous causes of syncope should also be excluded. However, if the patient is over 60 years old, then the likelihood of benign, vaso-vagal syncope is very small.

Causes of fainting:

  1. Syncope due to obstruction of cardiac output
    – Aortic stenosis
    – Mitral stenosis
    – Hypertrophic cardiomyopathy
  2. Syncope associated with cardiac arrhythmias
    – Bradyarrhythmias
    – Sinus node dysfunction
    – Tachy-brady syndrome
    – Conversion pauses
    – Atrioventricular block
  3. Tachyarrhythmia
    – Atrial fibrillation or supraventricular tachycardia (rare)
    – Monomorphic ventricular tachycardia:
    – structural heart disease
    – idiopathic ventricular tachycardia with a normal heart
    – drug-induced (proarrhythmia)
  4. Hereditary arrhythmia syndromes that lead to tachycardia of the “pirouette” type, polymorphic or bidirectional ventricular tachycardia.
  5. Violation of the regulation of vascular tone and blood volume.
    – Reflex syncope
    – Carotid sinus hypersensitivity
    – Situational syncope (coughing, laughing, swallowing, sneezing, orthostatic
  6. Cardiovascular neurological disorders that can lead to loss of consciousness.
    – Stroke
    – Epilepsy
    – Panic / somatization
    – Subarachnoid hemorrhage
    – Migraine
    – Concussion
  7. Other causes of fainting / fainting mimics
    – Hypoglycemia
    – Hyperventilation
    – Subclavian steal syndrome
    – Decreased blood volume
    – Carcinoid
    – Medicines
  8. Multifactorial syncope (multiple causes)

As follows from the above, a whole team of doctors should deal with the problems of fainting: a cardiologist, a neurologist, an epileptologist, an arrhythmologist.If fainting occurs in a public place, there is a high likelihood of hospitalization.

What do doctors and patients need to keep in mind?

About the fact that there are states that can manifest themselves as fainting, but at the same time are actually an interrupted sudden death !!!

This is:

  1. Postinfarction ventricular tachycardia
  2. Ventricular tachycardia in patients with dilated cardiomyopathy and systolic dysfunction
  3. Canalopathy (prolonged QT syndrome, shortened QT, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, ventricular tachycardia of the pirouette type, provoked by early (R to T) premature ventricular contractions.
  4. Hypertrophic cardiomyopathy
  5. Arrhythmogenic right ventricular cardiomyopathy

High-risk features that should alert both the fainting patient and the physician:

  1. Sudden syncope with minimal or no prodrome
  2. Injury during fainting
  3. The patient has cardiomyopathy, a previous heart attack or congestive heart failure.
  4. Family history of fainting, sudden death, death at night in young people, death associated with drowning, sudden infant death, unexplained road traffic accidents.
  5. Fainting during exercise.

What to do if you or your relatives faint?

  1. Contact a cardiologist at the Teremok Zdorovya clinic
  2. If there are relatives who have witnessed fainting, it is advisable to take them with you to the doctor’s appointment.
  3. If during the fainting, the ambulance team was called and an ECG was taken, then you must take it with you.
  4. If you have any medical documents on hand, such as previous examinations, tests, hospital discharge, you must take them with you.
    A cardiologist therapist will begin to carry out the necessary diagnostics: to exclude life-threatening arrhythmias or heart block (which are very often transient, i.e. intermittent and rarely recorded on a conventional ECG !!!)
    If necessary, other specialists will be connected: neurologists, arrhythmologists, epileptologists, etc.d.

Attention! If you fainted even just once, then the visit to the cardiologist cannot be postponed!

The doctor will find out the causes of fainting, select the necessary treatment, tell you in detail about your personal risks, some of the restrictions that arise in your life in connection with the diagnosis, write you a follow-up plan for the next years.
Restrictions may even apply to the use of certain drugs!

It must be remembered that it is not the fainting itself that is treated, but the disease that led to it.Diagnostics is often very difficult and it comes to using loop recorders. The European Society of Cardiology calls for a wider and more bold use of this diagnostic method. In some cases, the diagnosis ends with the installation of a pacemaker. In such difficult cases, it is necessary to get a second opinion in leading foreign clinics. Our cardiologist has such an opportunity😊))

Good luck to everyone, good health and a wish to see a cardiologist on time!

Austrian MP fainted while speaking at a meeting of parliament

https: // ria.ru / 20211013 / obmorok-1754459751.html

Austrian MP fainted while speaking at a meeting of Parliament

Austrian MP fainted while speaking at a meeting of Parliament – RIA Novosti, 13.10.2021

Austrian MP fainted while speaking at sitting of parliament

Austrian Social Democratic deputy Eva-Maria Holzleitner fainted while speaking at a meeting of the Austrian National Council (lower house of parliament), … RIA Novosti, 13.10.2021

2021-10-13T20: 54

2021-10-13T20: 54

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VIENNA, Oct 13 – RIA Novosti. Austrian Social Democratic MP Eva-Maria Holzleitner fainted while speaking at a meeting of the Austrian National Council (lower house of parliament), according to the Kronen Zeitung.The incident took place at an extraordinary session of parliament. Holzleitner experienced a fit of weakness right during her speech behind the podium. The fainting was quickly treated, and after a couple of minutes she returned to the meeting. Shortly after the incident, Holzleitner thanked colleagues who rushed to help her and said that she was feeling well.

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Austrian MP fainted while speaking at a parliament meeting

90,000 Dizziness and loss of consciousness

Approximately 30-50% of people experience fainting or “darkening of the eyes »At one stage or another in your life. Fainting occurs for a variety of reasons, but the immediate common cause is usually a sudden drop in blood pressure, which in turn causes a short-term reduction in blood flow and oxygen delivery to the brain.
Usually, but not always, a person immediately before loss of consciousness feels lightheadedness or dizziness, and may also complain of darkening in the eyes, ringing in the ears. In addition, nausea, vomiting, sweating, and a rapid heart rate or slow heartbeat may occur.
Syncope is so common among patients of various ages that many patients do not immediately perceive it as a serious threat to life, and may only seek professional help after a series of syncope, which is a mistake.
The most common type of fainting occurs due to improper reflex interaction of the cardiovascular and nervous systems, as a result of which the cardiovascular system chooses an inadequate heart rate and the degree of relaxation of the blood vessels of the body.
In addition to so-called functional or “reflex” fainting, patients may also faint due to organic heart disease: excessively fast or slow heartbeats, dysfunction of the heart muscle or heart valves, as well as diseases of the nervous system and overdose of drugs that lower blood pressure.
Differential diagnosis usually requires an electrocardiogram or “EKG”, as well as an ultrasound scan of the heart or “echocardiogram” and other methods.
A physician may recommend that patients who complain of recurrent reflex fainting avoid certain situations that lead to fainting (for example, standing on a crowded train in hot weather), wear medicated compression stockings, prescribe certain medications and, in some cases, establish pacemaker if heart rate is too slow to syncope
Certain non-invasive tests are available to diagnose heart muscle and / or heart valve disease, such as 24-hour continuous heart rate and rhythm recordings using an ECG (“Holter ECG”).
In some cases, invasive examinations may be required, such as coronary angiography (cardiac catheterization) and / or specialized examinations of the “electrical system” of the heart, known as “electrophysiologic examination or EPI”.
In patients with organic heart muscle disease, syncope often occurs due to an overly fast heartbeat. In such a situation, the heart simply does not have time to eject the amount of blood necessary to ensure the normal functioning of the brain, and the doctor may decide to perform special heart surgery to eliminate or cauterize the source of such arrhythmia (see.below). In some cases, the doctor may decide to implant a special device under the skin that resembles a pacemaker that will restore excessively fast heartbeats using an electric shock from the inside (see implantable cardioverter defibrillator).
In general, it should be concluded that in the event of fainting, one should not wait for its repeated recurrence (since the 2nd or 3rd may be the last), but quickly seek help from a specialist.

Treatment of fainting and loss of consciousness in Chelyabinsk

What we know as loss of consciousness or fainting, in medical language is called orthostatic collapse and represents the immobility of a person, as a result of which he cannot respond to any external stimuli.This condition occurs due to a sudden slowdown in metabolism and a sharp decrease in blood flow to the brain. Fainting is usually not life threatening in most cases.

Absolutely all reasons that can cause loss of consciousness are somehow connected with the brain, more precisely, with cell damage. If it is deep, cramps, involuntary twitching of the limbs, drooling and urination may occur. The duration can be from a few seconds to several minutes.

Main causes

  • A sharp decrease in hemoglobin.
  • Carbon dioxide poisoning.
  • Oxygen deficiency.
  • Traumatic brain injury.
  • Blood loss due to trauma.
  • Circulatory disorders.
  • Traumatic shock.
  • Toxic shock.
  • Anaphylactic shock.
  • Epileptic syndrome.

Often, the reason can be a psychological reaction to any stressful situation, as well as strong excitement, anxiety, fear, etc.e. As a rule, this is accompanied by a short-term loss of consciousness, which is not dangerous for human life.

The duration depends on the specific situation: it can be either long-term or short-term. The body reacts with both mild and deep loss of consciousness. In this case, reflexes appear very weakly, or are absent altogether, and the tone decreases.

Main symptoms prior to loss of consciousness

  • Nausea rolling in the throat.
  • Deaf and lingering ringing in the ears.
  • Multi-colored specks in the eyes.
  • Cold perspiration all over the body.
  • General feeling of great weakness.
  • Sharp pallor of the skin.
  • Rapid heartbeat.
  • Jumping heart rate.
  • Pressure drop.
  • Dilatation of the pupils.

As mentioned above, short-term loss of consciousness lasts from a few seconds to several minutes, while long-term fainting can last for several hours.And this already has serious consequences and requires medical intervention.

Treatment methods

For whatever reason a person loses consciousness, the first thing to do is call a doctor. But, while the ambulance is on the way, you need to provide the victim with first aid. You need to act quickly and not give in to panic.

What should be done if a person suddenly faints?

  • The victim should be laid on his side and his head should be tilted back a little.
  • If necessary, remove tight clothing and splash cold water on face.
  • In the room, open all windows and try to bring ammonia to your nose.
  • It is advisable to raise the patient’s legs, or to sit him down with his head lowered.
  • If a person regained consciousness – in no case allow him to get up quickly.

If it happened due to a sharp drop in blood pressure, which is the most common cause, then the victim’s legs can be wrapped with an elastic bandage – this will disperse the stagnant blood in the vessels.

In any case, an accurate diagnosis can be made by a doctor who will conduct an examination and prescribe the necessary treatment. The specialists of our center will provide you with qualified assistance!

Is fainting different from loss of consciousness?

Sometimes external factors act negatively on a person, and he loses consciousness or faints. Such phenomena are now common, but people who do not have medical training often confuse the phenomena. Without medical knowledge, it is quite difficult to distinguish loss of consciousness from fainting, although they differ quite strongly from each other.

Loss of consciousness is a long-term depression of the nervous autonomic system. In this case, an unconscious rather deep state is observed, which can cause coma, as well as a complete absence of reflexes.

Fainting in modern medicine is listed as syncope – a short-term loss of reason due to cerebral vascular insufficiency (mild), during which the brain feels oxygen deficiency due to the fact that blood does not enter it well.And this condition most often occurs due to unexpected oxygen starvation. The suppression of reflexes is also noticeable, the frequency of heart contractions decreases, and the pressure gradually decreases.

Recommended Action

If you see a person starting to faint, try not to fall and hit his head.

A sufficient volume of blood must be supplied to the brain. What instinctive reaction is triggered when a person loses consciousness? Of course, I want to help him.And if he is lying, there is a desire to put something under his head, but this is extremely contraindicated in the described condition. The fact is that when the head is raised, the outflow of blood is ensured from it. Thus, a person must be laid down so that his head is at least at the level of the body, and maybe even lower.

You can raise your legs, and then blood will begin to flow from the limbs to the head. Many advise leaving the unconscious person alone, letting him lie down, and he will come to himself.However, if patting the cheeks does not work, it is best to call an ambulance without letting things go by themselves. The victim may need immediate medical attention.

How does loss of consciousness occur?

A person becomes ill, he rolls his eyes and loses consciousness, gradually sinking to the floor. It is very rare that the victim falls as if knocked down. This will indicate the presence of other health problems. In any case, it is better to undergo a comprehensive examination, starting with a neurologist.

Fainting is not a sign of illness. For example, they are observed in perfectly healthy pregnant women at the sight of some kind of food. Therefore, everyone should understand how to behave if someone nearby fainted. If you do not know this and do not understand the principles of correct behavior, then at the sight of a fainting state, you can panic and, instead of helping, harm a person.

Who suffers from fainting?

So, most often syncope is caused by a lack of oxygen supply to the brain.This process is sometimes referred to as oxygen starvation. If we consider the statistics of fainting states in people of different groups, then we can see that it is impossible to single out a certain group according to some criterion.

Prone to fainting:

90,034 90,035 men and women;

90,035 people of all ages.

Professional affiliation also does not determine the group leading in fainting conditions. Sometimes people faint, for example, from fright or blood, or stuffiness or the sight of a spider.It is clear that these situations have nothing in common.

Prevention

What to do, or what should you worry about yourself if you encounter such a problem? If fainting has become more frequent, then, of course, first of all it is necessary to consult a neurologist.