Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name is Dr. Warrick Bishop and welcome to my podcast and videocast station. Today, I'd like to talk about what I'd like to talk about is syncope or blackouts. Now, you may have heard the term syncope and wondered what it means. Well, if you're a musician, you will have heard the term syncopation. And syncopation means... pauses or breaks in the music almost a staccato if you like it pauses so syncope derives from a word that means pauses and the medical term syncope really just relates to people blacking out and of course this is really important and as a cardiologist we see people who have blackouts or syncope. And in general terms, we have to work through a bit of a diagnostic filter or sieve to figure out what's going on. If you think about it, you can be fairly logical. People can blackout because of their brain. They may have a seizure, for example. So the brain could be a cause of a blackout. And often these people will have Perhaps some sort of prodrome, some sort of aura, some sort of warning before it occurs, maybe flashing lights. And their blackout may be characterized by the sort of violent shakes or tremors, the tonic, clonic contractions of an epileptic seizure. The heart can be a cause of people blacking out, the heart going too slow or the heart going too fast. So if the heart races very quickly, people may drop their blood pressure and black out, fall over. But if the heart has a pause, if there's a failure of conduction of the electrical signal of the heart, then equally the person or the individual may black out. And often if there's a sudden pause in the electrical activity of the heart, those people hit the ground like a sack of potatoes. It's a very compelling, sinkable or blackout episode and often will need further investigation. Blood pressure is a real common cause of blackouts as well. And that generally has a characteristic in that patients will describe a situation where they move from a position of rest to a position, a changed position, a postural change. such that they might be laying and get up and go to the bathroom or get up and move across the room. They may be sitting and get up and move across the room and they may have a moment's whizziness or lightheadedness and then black out. And that's because the blood pressure may be fine as they're sitting or laying in their bed, but when they stand, the body doesn't keep that blood pressure up and so the perfusion to the brain is inadequate. With inadequate perfusion to the brain, it shuts down and these individuals collapse or black out. There's another really important group that I want to share a story with you about today, and that's the blackouts that are related to the autonomic nervous system, the nerves that regulate the body speeding up or slowing down without us even thinking about it. autonomic nervous system the automatic nervous system because it reflects the fight and flight mechanisms so if we think we're going to be in a fight or we think we're in danger our heart speeds up and our blood pressure increases and blood flow to our muscles improves and our eyes dilate this is the sympathetic nervous system speeding us up equally we've got a rest and digest nervous system as well one that constricts our eyes, directs blood to the gut so we can digest, slows our heart rate down and often lowers our blood pressure. So these two automatic or what we call autonomic nervous systems work in conjunction together to make sure that our non-thinking bodily functions are undertaken as required. Now the interesting thing is that sometimes these get out of whack and particularly The slow down one, the parasympathetic nervous system, the one that is the rest and digest one, can sometimes be dominant and lead to a blackout. Now, when you get a blackout from that slow down nervous system being overactive, that generally is what we would call a simple faint. The sort of faint where you might feel a bit hot in the face. You feel a little bit unwell. You need some fresh air if you're in a hot room. And some people may have suffered this. It's the sort of faint that you might get if someone sees blood and they're not used to blood and they just pass out. Having a needle if you're a little bit needle phobic. Or having blood taken if you're a bit needle phobic. could be a sort of trigger for that simple faint. There's a couple of other things that make you faint. There's a situation where if you cough, or sometimes even if you're passing urine, you can have a blackout. These are not quite part of this discussion, but they can occur. They're uncommon, but they do occur, and they're very specific, can be addressed. The reason I wanted to talk about syncope today was that I had a patient recently who was a phone consultation at the other end of the state. So this patient, this lady in her 70s, was in the north of the state. Her GP had asked me to consult because she'd been having funny turns. I thought in the first instance I'll speak to this lady on the phone, save her a trip down to Hobart, and try and get a feel for what was going on before ordering tests or... pursuing a particular avenue of investigation. Well, this dear lady in her early to mid-70s had had about 10 years' worth of these funny turns. They were occurring fairly regularly, every week or two. She described that they were often in the afternoon, sometimes not far from meals. She'd be a bit hot and flushed and have some abdominal distress. Getting the clues sounds a little bit vasovagal, sounds a little bit simple faint, sounds a little bit like the slow down autonomic nervous system. Well, that's exactly what she described to me. I said to this lady, look, I don't know if this is what's going on or not, but I'd like to try a couple of things. Now, historically, we used to use what we call beta blockers to slow, which slow the heart down. Because contrary to what you'd imagine, This particular slow down sort of feint starts off with a very brief and brisk acceleration where the heart takes off quickly before it drops off rapidly. So historically we've used beta blockers to try and dampen that initial uptick of the heart rate. Now I've used that over the years for a number of patients and it has been effective. It's dropped out of current guidelines and not considered. a first line therapy or a therapy at all but I must say I still see its benefit in certain individuals and I'm happy to try it as a first line. I also thought with this lady I'd give her a little bit of what we call an anticholinergic agent. Now anticholinergic you don't need to remember but it's a sort of a belladonna type thing and really what it does is it blocks the cholinergic pathway which the slowdown or the parasympathetic nervous system drives. So in this particular case, I was looking to bracket this lady's responses. Slow down the rapid uptake or the rapid uptick of her heartbeat with the beta blocker and to prevent or attenuate the slowdown by trying to blunt that parasympathetic or vasovagal response at the bottom. So I put her on low doses of beta blockade and an anticholinergic, and an anticholinergic which is available over the counter is called BuskPam. So we put those in place. Lo and behold, several months later, I called a patient in from the waiting rooms. This lady sat down. I didn't recognize her. I said, hi, how are you going? She said, I'm going very well. Thank you, doctor. You fixed me. I said, I don't even know who you are. I'm sorry. Please refresh me. She said, I'm the lady from up north who was having the funny turns. I haven't had one since. Thank you so much for what you've done. And I have to say, I was absolutely stoked that we were able to avert this lady's symptoms from getting a really clear history, which pointed exactly to the condition that we're talking about. And we're able to put in place the strategies that could modify the body's response. She'll stay on that long term and hopefully remain happy and out of any problems at all. They're low doses. They're not going to carry any major risk. And she's happy. And I'm absolutely stoked that I was able to help someone who I didn't even see. So what I'd like to do is wrap up with blackouts and syncope. And they are important. It's really important. You go and see your doctor. It's really important. that you probably see a cardiologist because there are issues about driving as well. And in certain situations, we do have to put in place driving restrictions for periods of time or you need exemptions. So whatever happens, think about what you're going to do if you have a blackout. I strongly suggest you see your doctor and get reviewed by a cardiologist. It's a really important, really quite a common situation. and one that we can do something about. I hope that you found this podcast on blackouts and syncope informative, interesting, and plenty to think about. If you've got any queries or questions, drop us a note at, well, it'll be members at DrWarrickBishopOnline and we can answer your queries or questions. Until next time, of course, I wish you the very best and please don't die from a heart attack. Goodbye. You have been listening to another podcast from Dr. Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
