What is Syncope?

Podcast Transcript

Announcer:

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Oussama Wazni, MD, MBA:

Hello, everyone, and welcome once more to the Cleveland Clinic Electrophysiology podcast. I am Oussama Wazni. I'm the Section Head of EP here at the Cleveland Clinic. And today with me, I have Dr. Ken Mayuga, the Director of the Syncope Center. Welcome, Dr. Mayuga.

Kenneth Mayuga, MD:

Thank you, Dr. Wazni.

Oussama Wazni, MD, MBA:

All right. Ken, could you tell us about our Syncope Center?

Kenneth Mayuga, MD:

Sure. Wonderful. Thank you for having me, Dr. Wazni, on this podcast. It's my privilege to be here this afternoon. As you asked, the Syncope Center here at Cleveland Clinic is very unique. We are a comprehensive outpatient clinic designed to evaluate symptoms and conditions, including syncope and related symptoms that could be anything from lightheadedness to palpitations to passing out or almost passing out, shortness of breath. We're very well equipped to evaluate these conditions and treat the underlying reasons that people have them.

Oussama Wazni, MD, MBA:

Can you tell us a little bit about syncope in general? What are some of the conditions that make patients pass out or feel as if they're going to pass out?

Kenneth Mayuga, MD:

It's a great question. In general, people pass out from not enough blood going to the brain, and that can happen for many reasons, but mainly for low blood pressure or really slow heart rates or really abnormally fast heart rates. And then you have other reasons, including seizures and low blood sugars, et cetera. But the main things we're concerned about are transient loss of consciousness because of blood pressure, heart rate or heart rhythm issues.

Oussama Wazni, MD, MBA:

Based on what you know and your vast experience in the Syncope Center, when should we tell a patient that this sounds really serious? Or maybe this is not so serious? Because these are some of the questions that we're faced with every day.

Kenneth Mayuga, MD:

That's a very appropriate question. When we look at passing out, it can range from the common faint, also known as vasovagal syncope, to more concerning things, such as arrhythmias or abnormal heart rhythms. I believe it's always a good idea to check in with your primary care provider or pediatrician to make sure that what you have is not as concerning. Otherwise, we're more than happy and more than capable of evaluating for these more concerning conditions, such as arrhythmias or malignant vasovagal. And we're happy to investigate that further.

Oussama Wazni, MD, MBA:

Just quickly also, I know that I have a lot of patients who come seeking our help for POTS. Can you tell us what is POTS, and is it something that is serious or is it something that we can manage?

Kenneth Mayuga, MD:

So POTS, otherwise known as postural tachycardia syndrome, is defined as a heart rate increase by at least 30 beats per minute when going from supine to standing position, but it can cause many symptoms.

Oussama Wazni, MD, MBA:

That's from lying down to standing up.

Kenneth Mayuga, MD:

Exactly right. The key word here is postural, so it happens when you're upright. But it can cause a lot of symptoms. It can cause feelings that your heart's racing or lightheadedness or almost passing out to chest pain or shortness of breath. It can be very cumbersome for patients, very debilitating. While it is considered, in general, a benign condition, it can be very symptomatic, and so I do urge people to seek care for this.

Oussama Wazni, MD, MBA:

Just to summarize for our patients, POTS means that when an increase in heart rate that you can feel, with palpitations - palpitation means fast, rapid heartbeats - when going from a lying down position or sitting down position to a standing up position. That's basically the meaning of POTS. It's usually benign, but it can cause a range of symptoms that can be very difficult for our patients to deal with.

Kenneth Mayuga, MD:

Exactly.

Oussama Wazni, MD, MBA:

Let's go back now to syncope. What are the things that we have here at the Cleveland Clinic? And also you can touch on our experience that we can manage or evaluate patients with recurrent syncope, meaning passing out, recurrent passing out. What is our approach to the treatment management and treatment of those patients?

Kenneth Mayuga, MD:

Wonderful. The Syncope Center here at Cleveland Clinic is unique. We have two highly-trained cardiac electrophysiologists. We have a group of nurse practitioners. We have five nurses, two nuclear medicine technicians, all working together to try to find out why people pass out.

Kenneth Mayuga, MD:

Again, I mentioned we have cardiac electrophysiologists, who are specialized in looking for cardiac reasons to pass out including arrhythmias, such as AV block or sinus node dysfunction, that cause your heart rate to become very slow, or other cardiac conditions such as hypertrophic cardiomyopathy that can cause people to pass out. We can assess for those two, so we're very trained in the cardiac aspect of things.

Kenneth Mayuga, MD:

However, while we are very trained in the cardiac aspect of things, we are also very experienced at helping patients with related conditions, such as POTS, vasovagal syncope, and orthostatic hypotension. Our evaluations here include the best of Cleveland Clinic. We have cardiac MRIs. We have echocardiography, we have outpatient cardiac monitors, event monitoring, mobile continuous outpatient telemetry, all geared towards looking for dangerous, concerning cardiac reasons to pass out.

Kenneth Mayuga, MD:

If it is thought to be more orthostatic or reflex syncope, we have a full range, a complete range of evaluations for that. We have tilt table testing, blood volume testing, hemodynamic testing, autonomic function testing, including quantitative pseudomotor axon reflex testing, Valsalva testing, skin biopsy for nerve fiber density. We run the full range so we can try to identify what's causing your symptoms, no matter what it is. We are very, I suppose, unique in that regard.

Oussama Wazni, MD, MBA:

Just to recap here, while we have a comprehensive range of things we can do to diagnose, it's also a tailored approach. What you decide to do for a patient or a study that you decide to pursue, will depend on the history and based also on your experience of what's happening to a patient. Not every patient will end up getting an MRI or all of these tests. I just want to make sure we clarify that. But it will really depend on the presentation, on how a patient comes to the office, and then based on the clinical history and also based on what has been done before, because most of our patients are also looking for second opinions. Then we can pursue any or all of these as needed in a particular situation. Correct?

Kenneth Mayuga, MD:

That's exactly right. It all starts with an outpatient visit, where we listen to the patient, we see what's the most concerning questions, we see what's been done before, and we plan together, in a collaborative approach what our plans would be to further evaluate this. We work together with the patient, with their referring physician, if they have one, and we plan out the appropriate evaluations and then find out what's causing things. And then we work on the management together.

Oussama Wazni, MD, MBA:

Thank you. Thank you. Finally here, any new things on the horizon regarding overall management and also treatment of these conditions?

Kenneth Mayuga, MD:

That's a very broad question. I will answer that in a way that is particular to us. If we have a cardiac reason for syncope, we're more than capable of putting in pacemakers to treat AV block or bradycardia. We can put in defibrillators to treat dangerous ventricular arrhythmias. On the other hand, we are very experienced with using medications that other people may not be as familiar with.

Oussama Wazni, MD, MBA:

Thank you. Thank you so much. And thank you all very much for your attention. I hope you found this helpful, and hopefully, we'll see you in the next podcast.

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