Please HELP - case study

Dinith88 · Jun 2, 2005

Christian_SN said:

Patient had pacemaker placement. 1 mo later patient is still having episodes of pre-syncope and a heart drop >256x's. Patient is unable to have intercourse with wife.

I'm not sure what is meant by 'heart drop'. If you mean his heart-rate slowed enough to cause symptoms then his pacemaker either A) needs to have the pacer/low-rate readjusted or 2)the pacemaker isn't working??? (has he had it checked??)

'Pre-Syncope' is kind-of a vague symptom/complaint where the patient feels like he/she's about to pass out. Could-be a WHOLE LOT of reasons for this...not soley bradycardia.

I'm doubting it's related to his heart-rate because I'm seriously doubting such a new pace-maker would be malfunctioning (has he had it checked??). Also, an episode of hypotension isn't always related to or caused by bradycardia.

Anyway, in a nutshell I guess I don't have an answer for you.

Christian_SN, RN · Jun 2, 2005

Dinith88 said:

I'm not sure what is meant by 'heart drop'. If you mean his heart-rate slowed enough to cause symptoms then his pacemaker either A) needs to have the pacer/low-rate readjusted or 2)the pacemaker isn't working??? (has he had it checked??)

'Pre-Syncope' is kind-of a vague symptom/complaint where the patient feels like he/she's about to pass out. Could-be a WHOLE LOT of reasons for this...not soley bradycardia.

I'm doubting it's related to his heart-rate because I'm seriously doubting such a new pace-maker would be malfunctioning (has he had it checked??). Also, an episode of hypotension isn't always related to or caused by bradycardia.

Anyway, in a nutshell I guess I don't have an answer for you.

heart rate drop - pacemaker is set to work when the heart starts to drop at a fast rate... 15 beats (or somthing like that... this is new to me) like when a syncope episode is about to or is happening.

the pacemaker is working great but syncope episodes are still occuring.

pre-syncope , u had right on... is a dizziness - a feeling of almost passing out.

bonner is not the issue, rather pre-syncope and chest pain during/after climax.

any add. help you have would be great. thanks

this patient has a lot of nurses and physicians wondering what is going on... ekg are fine. I of course do not know what to make of the heart (?) problem.

begalli · Jun 2, 2005

Has he been checked for hypoadrenalism? Some of the s/s of this are syncope. fatigue, low bp, low hr.

I don't know much about hypoadrenalism and the only reason I suggest this is because my daughter was having the opposite problem. She's 26, was having hypertension, tachycardia, was always on edge like she would have a panic attack. After ruling out a dozen other problems they had her collect a 24 hr urine for pheochromocytoma - a condition of the adrenal glands.

Probably a shot in the dark, but you never know.

gizelda196 · Jun 2, 2005

Have they interogated the pacer? Has he been cathed?

Dinith88 · Jun 2, 2005

Pacemakers work in whole lotta different ways. You'll learn more about pacemeakers when you're out of school and if/when you start dealing with them. Simply put, the PM 'watches' (senses) your heart rate and when it falls to a certain rate (50-60-70 usually, but can be higher or lower) it then 'paces' your heart to ensure the rate doesnt fall below the pre-determined threshold. But it has no way of knowing that a syncopal episode is about to occur (yet! Give it a few years :) )

If PM is 'working great' then forget about the whole bradycardia thing, as it's obviously not the culprit at this point.

If, as you say, syncope is still occuring then this person needs to stop driving, etc. until a proper diagnosis/treatment can be had.

Hypotension is still a potential (and until proven otherwise the primary) cause of this pre-syncope/syncope.

'Neurocardiogenic syncope' is a fancy way to say someone is vagaling. (look into vasovagal response/syncope). People 'vagal out' for lots of reasons (pain, surprise, fear, stress, etc.) and some unlucky people have 'hyper-sensitive' vagus-nerves. This could very well be the case here. Although the PM is protecting against symptomatic bradycardia, it wont help with the vasodilitation associated with a 'vagal response'.

Now, the whole chest-pain with sex is troubling and needs adressing (someone mentioned angiogram). I'm sure with all these troubled doctors puzzling over this case that at least one has considered this...

joyful nurse · Jun 2, 2005

There is a syndrome called Shy-Draeger's that is a progressive neurologic disorder that keeps the vessels from vasoconstricting in response to activity, etc, and often will present with syncope, low BP, etc. Usually diagnosed by neurology, but I thought it usually was older people.

heart queen · Jun 3, 2005

has your team considered a vagal nerve stimulator?

Christian_SN, RN · Jun 4, 2005

Has he been checked for hypoadrenalism? Some of the s/s of this are syncope. fatigue, low bp, low hr.
I don't know much about hypoadrenalism and the only reason I suggest this is because my daughter was having the opposite problem. She's 26, was having hypertension, tachycardia, was always on edge like she would have a panic attack. After ruling out a dozen other problems they had her collect a 24 hr urine for pheochromocytoma - a condition of the adrenal glands.
Probably a shot in the dark, but you never know.

thanks for the reply. i wrote hypoadrenalism down to look into... like his labs and ect...

thanks for your help

Christian_SN, RN · Jun 4, 2005

Have they interogated the pacer? Has he been cathed?

yes inspections (interogated?) have been done.

no cath has been done....

very ekg looked fine,,, :uhoh21: ...

he did have absent P wave after pacement of pm which is back now.

i hope that i did answer ur question... i am learning... doing my best.

thanks for you reply and care

Christian_SN, RN · Jun 4, 2005

Pacemakers work in whole lotta different ways. You'll learn more about pacemeakers when you're out of school and if/when you start dealing with them. Simply put, the PM 'watches' (senses) your heart rate and when it falls to a certain rate (50-60-70 usually, but can be higher or lower) it then 'paces' your heart to ensure the rate doesnt fall below the pre-determined threshold. But it has no way of knowing that a syncopal episode is about to occur (yet! Give it a few years :) )
If PM is 'working great' then forget about the whole bradycardia thing, as it's obviously not the culprit at this point.
If, as you say, syncope is still occuring then this person needs to stop driving, etc. until a proper diagnosis/treatment can be had.
Hypotension is still a potential (and until proven otherwise the primary) cause of this pre-syncope/syncope.
'Neurocardiogenic syncope' is a fancy way to say someone is vagaling. (look into vasovagal response/syncope). People 'vagal out' for lots of reasons (pain, surprise, fear, stress, etc.) and some unlucky people have 'hyper-sensitive' vagus-nerves. This could very well be the case here. Although the PM is protecting against symptomatic bradycardia, it wont help with the vasodilitation associated with a 'vagal response'.
Now, the whole chest-pain with sex is troubling and needs adressing (someone mentioned angiogram). I'm sure with all these troubled doctors puzzling over this case that at least one has considered this...

All I really know which is not much is... the PM detects if his heart rate falls at a fast pace (15 beats) then kicks hr up to 90 for 1 min. His lower rate is set at 60 bpm. I only said that so I can learn if I do have this right? And to learn more from ur replies.

Bradycardia is not a problem b/c PM has a set rate at 60 bpm..... Right?

Not that I am stereo type... but he is a male... very much a white coat syndrome. Just getting him to tell us what is going on is a big challenge (the wife gives most/all the information). I do not know if he is driving all the time, but after every discharge -he is at work the next day. -I think there is some denial of his problems. :uhoh3:

Hypotension makes a lot of sense, now. I did not know if it was the heart causing the syncope or vagal response causing the heart. It is very difficult to understand what causes what, I have researched but to no avail.

'Neurocardiogenic syncope' diagnosis is not a great diagnosis to me, call me crazy. I feel with his symptoms then it must be heart.? I thought if it was heart it could be the ONLY thing that could explain the *astyloic >5 sec (which he had 30 sec) on the table test? I thought I read that in my research, is this right?

So he would need an angiogram? He is scheduled for a stress test on tues.

Christian_SN, RN · Jun 4, 2005

There is a syndrome called Shy-Draeger's that is a progressive neurologic disorder that keeps the vessels from vasoconstricting in response to activity, etc, and often will present with syncope, low BP, etc. Usually diagnosed by neurology, but I thought it usually was older people.

thanks, i'll look into that... thanks again