Recurrent Syncope in a 32-year-old Woman: Anxiety?

History: A 32-year-old woman presents to the emergency department (ED) for a dental injury and lip laceration caused by a syncopal episode. She states that prior to fainting she had a few minutes of palpitations and a feeling of doom. She has fainted 3 other times in the past 6 months, but this is the first time she injured herself because the other times the symptoms started while she was seated or when there was someone there to catch her. The first time it happened she saw one of your ED colleagues and was diagnosed with syncope and a panic attack, so the other two times she decided to just stay at home. She only came this time because of the broken tooth and cut lip.

Examination: Vital signs are normal. Exam is normal except for a fractured upper incisor and a 1.5-cm upper lip laceration. She has no spinal tenderness and heart and lung sounds are both normal. Orthostatic vital signs are obtained and are normal.

Differential Diagnosis:

 -- Dysrhythmia

 -- Panic attack

 -- Hyperventilation syncope

Initial Testing: Results of CBC, HCG, and metabolic panel are all normal; her ECG tracing is shown in Figure 1 at upper right (please click to enlarge).

Questions:

1. What are the ECG findings? 2. What should you do next?

Please click "next" for answers and discussion.

Answers

1. What are the EKG findings?  ECG shows Brugada type 1 pattern
 

2. What should you do next? Consult cardiology, admit patient to telemetry, and read highlighted area on page shot below for review.

Discussion

There are many causes of syncope and discussion of all of them is beyond the scope of this report. Some traditional red flags for a serious cause of syncope include:

 -- Older age

 -- No clear vasovagal trigger

 -- Onset of symptoms in a seated or lying position or with exertion

 -- Lack of any warning symptoms such as light-headedness or warmth, and

 -- Presence of pain, dyspnea, palpitations, or other symptoms that suggest the cause is not vasovagal

Interestingly the teleologic reason for the vasovagal reaction, which typically causes bradycardia and hypotension, may be to minimize blood loss after an injury.

Testing for syncope should always include an ECG and orthostatic vital signs. If those are both normal and there are no additional symptoms or red flags on the history or exam, additional testing or treatment is rarely required. The page shot in Figure 2 (above) shows a number of ECG findings to check for in a patient with syncope when there is no evidence or more obvious findings such as tachycardia, bradycardia or ischemia. The most common of these ECG findings that signal a propensity for serious dysrhythmias are interval related findings, eg, long QT interval or short PR interval with Wolff Parkinson White syndrome and Lown Ganong Levine syndrome.

The Brugada pattern is NOT an interval-related ECG finding and typically includes down-sloping or saddleback morphology ST elevation in the anterior precordial leads V1-V3 that is often, but not always, associated with T-wave inversion and/or right bundle branch block. These findings can be intermittent. There are three different Brugada ECG patterns, shown in Figure 2. Patients with syncope and one of these ECG morphologies should have electrolytes and troponin evaluated and be admitted to a telemetry bed with cardiology consultation. Definitive treatment usually involves placement of an automatic implantable cardioverter-defibrillator (AICD).

Case conclusion: An AICD was placed and the patient's family was screened for Brugada.