Matt

The 20-year-old man awoke to the bright April sunlight and the strange feeling of déjà vu. It was a sensation he had come to know well over the last few months and one that signaled the start of one of these episodes that now dominated his life. He shook his girlfriend awake. “Talk to me,” Matt pleaded. By now, she knew what he meant and immediately began chatting about a hike they’d taken last fall with his new puppy and some friends. Should we go back today? It’s supposed to be a beautiful day. She watched him anxiously as she spoke. His face was pale, and the dark circles under his eyes looked even darker than usual. After a minute or so, Matt took a deep breath and shook his head as if the movement itself could clear his mind.

I’m O.K., he said at last. Just a little nauseous. Sweat gleamed on his face.

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A Trip to the Emergency Room

Matt had been having spells like these for over a year. The first time it happened, he was on the floor playing tug-of-war with his puppy. He had the same creepy déjà vu feeling, the same cold sweat, the same nausea. He didn’t feel himself lose consciousness, but suddenly the puppy and the rope were gone. He looked up and saw the pup gnawing on the rope in a different room.

He found his mother and was telling her what happened when suddenly he slid to the floor, unconscious. His arms and legs jerked a few times, and then he was still. He opened his eyes after maybe 30 seconds, but he couldn’t get up or even try to speak for another several minutes. Terrified, his mother drove him to Frederick Memorial Hospital, in Frederick, Md., the next town over. During the ride, Matt fainted again.

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She pulled the car up to the Emergency Department and ran in to get help. He had just been hooked up to the IV and the heart monitors when the young man passed out once more. This time what was happening was visible on the cardiac monitor: His heart was beating at a regular rate when, suddenly, it slowed and then stopped. The line on the monitor went flat. After a few seconds there was a beat and another brief pause, and then his heart started beating again as if nothing had happened. A temporary pacemaker was placed, and he was admitted to the intensive care unit.

The next morning Matt was seen by a cardiologist who specializes in the heart’s electrical system — the nerves and connections that run the rate and rhythm of the heart as it beats. He got the whole story from Matt and his mother. The young man had never fainted before. And, before this, had no medical problems at all. No one in his family had heart problems or fainted regularly. No one had died suddenly for unknown reasons — which might suggest a hidden and potentially inheritable heart problem. He didn’t drink or smoke, did occasionally use marijuana — though none lately — and worked out frequently.

The cardiologist examined the young man carefully. He appeared healthy, and his heart exam — indeed, his entire exam — was completely normal. An EKG done the night before, after his loss of consciousness, was also normal. An echocardiogram, an ultrasound of the beating heart, showed that Matt’s heart was moving normally. The specialist reviewed the strip recorded during his fainting spell and saw how the heart had paused for several seconds before resuming its usual rhythm. Matt was monitored constantly over the next several days. There were no pauses or other abnormalities seen.

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What Causes Fainting Spells?

Fainting, or what is known medically as syncope, is a transient loss of consciousness caused by reduced blood flow to the brain, usually from a heart that isn’t beating well enough to get the blood where it needs to go. Although the heart is involved in syncope, the problem doesn’t usually originate there. The usual trigger is the nervous system. Vasovagal syncope (VVS), the most common form of nerve-induced fainting, occurs when the heart gets an unneeded signal to slow down. The vagus nerve is designed to slow down the heart when it is beating rapidly because of fear, exertion or sex — but if triggered when the heart isn’t racing, the patient can faint when the vagus causes the heart to slow.

It’s not always necessary to identify the precise cause of syncope, but it is essential to make sure that it is not caused by the heart. So-called cardiac syncope accounts for only about 20 percent of all fainting spells. But because this kind of syncope can indicate heart disease, it’s important to separate patients with cardiac causes from those other reasons for fainting. Research has shown that those who have cardiac syncope have a higher risk of death, presumably from the underlying heart problem.

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About half of the time the patient’s own story will provide the most important clues to the cause of a syncopal event. The biggest clues include the patient’s age and gender and if there is a history of heart disease. The patient’s recollection of what happened just before the loss of consciousness is also crucial. The classic story for cardiac syncope is a middle-aged man who suddenly finds himself on the ground with no preceding symptoms and no awareness of the fall. An EKG may reveal a heart attack or arrhythmia, but often does not.

Vasovagal syncope usually has a very different story. Patients with this type of syncope are frequently young and describe feeling lightheaded or “faint” before losing consciousness. This sensation is often associated with breaking out in a cold sweat and nausea followed by a sense of narrowing vision — as if entering a tunnel. Upon awakening, patients will often describe a profound fatigue. And this type of syncope often follows some unpleasant stimulus — typically fear, or heat, pain or stress.

This young man had elements of a classic story of vasovagal syncope: Each instance was preceded by a feeling of faintness, nausea and a cold sweat. And when Matt woke up, he often felt very tired. But there were abnormal qualities to it as well. Most of the time, VVS occurs only once. A quarter of those who have this kind of fainting event will eventually have a second or even a third fainting spell. Having so many episodes one right after another, however, was unusual. Another oddity was that they often happened while Matt was lying down. Usually VVS occurs when the subject is upright. VVS is also frequently associated with some unpleasant experience. Not so in this young man’s case. And finally, the patient’s sense of déjà vu and the brief hallucinations he had sometimes before the events sounded more like a seizure than syncope. On the other hand, the strip obtained from the cardiac monitor while the patient was in the ED strongly suggested a neurally mediated, classic vasovagal faint with a sudden slowing of the heart.

Because the young man’s story didn’t fit the classic picture of VVS, the doctors caring for him in the hospital wanted to make certain his heart was not involved. He was tested for the common causes of cardiac syncope — Lyme disease and thyroid disease. He didn’t have Lyme disease, and his thyroid test, while not completely normal, was unlikely to have caused him to faint. After watching him on a cardiac monitor for four days, his doctors thought he was safe to send home. Still, because his story was a little atypical, a loop monitor was implanted in his chest. This monitor would record any abnormal heart rhythms.

After leaving the hospital, the patient’s primary care doctor referred him to a cardiologist at Johns Hopkins in nearby Baltimore. After reviewing the young man’s hospital records and listening to his story, the specialist massaged Matt’s neck just below the ear on each side, where the carotid arteries lie. These vessels, which carry blood from the heart to the brain, have receptors that help regulate how fast the heart beats. Some people have a strong response to even mild stimulation of the carotid, causing the heart to slow down. Matt’s reactions, however, were normal. He also had the young man increase his intra-abdominal pressure by pushing the way you might push to have a bowel movement. This can stimulate the vagus nerve and send signals to the heart to slow down and is thought to be one of the reasons some people can faint after urinating or moving their bowels. Matt’s heart slowed down a bit — as was normal. Neither seemed likely to cause syncope. The cardiologist ordered an MRI of the heart to look for diseases that can interfere with a normal heart rate by infiltrating the muscle and interfering with the heart’s electrical system. The images were normal.

Matt’s primary-care physician also sent him to a neurologist. The neurologist ordered an MRI of his brain, which came back normal. An EEG was also normal. (You can see these reports here.)

For the next six months, the monitor implanted in Matt’s chest didn’t show any unusual activity. He had no more sensations of déjà vu and no more fainting. Finally, patient and doctor agreed that the monitor could come out. They didn’t have a firm answer about what had happened, but it seemed to have resolved itself.

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Not Yet Out of the Woods

Two weeks after the monitor was removed, Matt was getting ready to take a shower when he suddenly had that strange feeling of déjà vu again. He was headed toward his bedroom to lie down when he suddenly blacked out, hitting his nose on the sink. He woke up in a pool of blood with a cut on the bridge of his nose. He was taken back to Frederick Memorial Hospital. Once again, he was hooked up to the cardiac monitor. And remarkably, once again his heart stopped, this time for nine seconds. Then there was a beat, followed by another long pause. A code was called and a defibrillator rushed to his bedside, but his heart restarted itself before a shock was needed. A temporary pacemaker was again placed and the cardiologist who saw him the first time consulted. A second Lyme test was done, as well as a second set of thyroid tests. This time both were unremarkable.

The cardiologist still felt confident that this was vasovagal syncope. He watched the patient overnight: Nothing irregular was seen on the monitor. The temporary pacemaker was never needed. He explained to Matt and his parents that putting a permanent pacemaker in someone so young was a bad idea and probably unnecessary. He could start Matt on a medication that would stimulate his heart and keep his blood pressure up and see if that was helpful, but he didn’t need to be in the hospital. (You can see a few notes from that hospitalization here.)

After being discharged, Matt returned to his cardiologist at Johns Hopkins. That cardiologist also thought that this probably was vasovagal syncope. When the medication started in the hospital seemed ineffective, he tried others. None seemed to work. (You can see the notes from this cardiologist here.) Matt’s primary-care doctor sent him to another cardiologist for yet another opinion. This doctor tried a different type of cardiac monitor for almost two weeks. It would record any abnormal rhythms; additionally, when the patient felt any symptoms — like the déjà vu sensation he’d had in the past — he was to press a button on the monitor, and the device would record his heart’s activity at that time. The patient pressed the button nearly every day, but the monitor showed only a normal or sometimes elevated heart rate with a normal rhythm. (Notes from that cardiologist and the results of the monitoring can be seen here.)

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Frequent Episodes

It has been more than a year, and the patient has continued to have episodes of déjà vu, accompanied by cold sweat and lightheadedness, once or twice a week. Most of the time he can somehow keep himself from passing out. The near-syncopal event he had in April, while with his girlfriend, resolved with rest alone. Having someone talk to him, he feels, sometimes short-circuits whatever is happening in his brain and keeps him from losing consciousness.

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Still, the episodes where he loses consciousness have persisted. A few weeks ago he was at work and tried lifting something heavy. Suddenly he was once again overcome with a sensation of déjà vu. It was followed by the nausea and cold sweats he has come to know so well. Seconds later, he found himself on the ground. He has had to take time off from work. His employer was concerned about why his apparently healthy employee had suddenly passed out, and he isn’t sure Matt should come back until he has some answers.

Matt is now seeing a third cardiologist. He is scheduled to have additional testing this week. (Notes from that cardiologist can be seen here.)

What do you think is going on here? Do you recognize this condition? Is this vasovagal syncope, or is there something else going on? What should Matt and his doctor look at next?

Enter your comments below, and briefly describe your thinking; how a diagnosis is made is often as revealing as the diagnosis itself. All answers will be reviewed, and the most promising diagnoses will be shared with the patient and his primary-care physician.

I’ll post an update in the coming days.