Syncope, or fainting, can be caused by a number of different things. Some of the most common problems with fainting come from a sudden change in position and the corresponding drop in blood pressure that can come with that. Additionally, other causes for syncope are anemia and cardiovascular problems. Syncope that comes from cardiovascular issues can be among the most serious, since heart-related problems can often lead to significant health problems and even death. In order to fully address syncope issues that come from cardiovascular problems or anemia, one must understand how these issues should be treated and what kinds of treatment plans work the best for each individual patient.
Syncope -- Cardiovascular and Anemia
The purpose of this study is to increase understanding of evidence-based management of a common problem encountered in primary care. The problem addressed here will be syncope (fainting) as is caused by either cardiovascular issues or anemia. Diagnosing the patient correctly is critical, as there are a number of causes for syncope (Jamjoom, Nikkar-Esfahani, & Fitzgerald, 2009). Once the issue has been correctly diagnosed, it is then time to come up with a management plan to ensure proper maintenance of the condition (Freeman, 2011). This is expected to reduce or eliminate the syncope, and will generally involve treating the condition that led to the syncope, rather than the fainting itself.
With correct treatment of the underlying condition, the syncope as a symptom should disappear (Ruwald, 2014). Children, adults, and senior citizens all react to medications and treatment plans differently, so the plan has to be tailored to the age group to which the person belongs and then to the specific person (Freeman, 2011). Then, a follow-up is necessary to ensure that the treatment plan is working properly and the patient is receiving maximum benefit from any medications and other modifications that have been prescribed (Dicpinigaitis, Lim, & Farmakidis, 2014).
Syncope is more commonly called fainting, and the reason it happens is from low blood flow to the brain (Ruwald, et al., 2012; Gauer, 2011). This typically takes place because a person shifted position or stood up from a sitting or lying position too quickly, resulting in a drop in blood pressure and a lack of ability to retain consciousness (Ruwald, et al., 2012). The episodes come on quickly, and they often resolve quickly, as well. People recover from them spontaneously, in most cases (Gauer, 2011). People who experience syncope find that they often have sweating, dizziness, a loss of vision or hearing, nausea, and other symptoms before they faint (Gaynor & Egan, 2011). This is pre-syncope, and is not always followed up by true syncope (Dicpinigaitis, Lim, & Farmakidis, 2014).
Patients with syncope are extremely common, as approximately 40 to 50% of people will have at least one episode of syncope in their lifetime (Manisty, Hughes-Roberts, & Kaddoura, 2009). This is more common in teenagers and in the elderly, but can happen to people of any age (Ruwald, et al., 2012). Because there are a number of benign and not so benign conditions that can cause syncope, determining whether the event was something serious or just a one-time issue that resolved itself is very important. There are several ways to do that, and all involve examination and testing by a doctor or other medical professional (Dicpinigaitis, Lim, & Farmakidis, 2014). A physical exam is the first option, and that examination can lead to the need for other testing in order to provide a diagnosis.
Diagnosing syncope itself is not difficult, but diagnosing what caused it correctly can be more complicated. A physical examination is the first thing that will need to be done for anyone presenting with syncope, no matter what their age or other conditions (Moya, et al., 2009). This can help find a simple cause for the issue, or could rule out potential reasons the person fainted. The medical professional will also take a thorough history, and electrocardiography (an EKG) will be performed (Reeves & Swenson, 2012). This can provide information on the rhythm of the heart. Anything other than normal sinus rhythm could be a cause for the syncope, and will be further investigated.
Electrocardiograms are generally conducted on anyone who has experienced syncope, in order to ensure that it was not caused by a cardiovascular issue (Dicpinigaitis, Lim, & Farmakidis, 2014). If there are abnormalities on the EKG, other heart tests will likely be ordered. These can include stress tests, echocardiograms, and related types of testing (Moya, et al., 2009). After the results of the EKG are examined, the patient will either be evaluated for orthostatic hypotension or syncope that is neurally mediated, or the syncope will remain unexplained at that point (Ruwald, 2014). If the syncope is neurally mediated or as a result of orthostatic hypotension (low blood pressure upon standing), the evaluation will generally be completed at that time (Ruwald, 2014; Gauer, 2011). Unexplained syncope requires further examination, in order to determine a cause.
Those with unexplained syncope are generally subjected to an echocardiogram, to look for other heart-related issues that might have caused the fainting episode (Ruwald, 2014). An evaluation for ischemia and a graded exercise test are also common diagnostic tools to rule out heart problems in unexplained syncope (Gauer, 2011). The graded exercise test, ischemia evaluation, and echocardiogram will either come back normal or abnormal. Carotid stenosis or a heart block are two common reasons for abnormal EKGs and other tests, and are also common reasons for syncope to occur. If any or all of the tests come back abnormal, there are treatment options available based on which test come back with an abnormal reading. When tests come back normal, there are also different steps that can and should be taken. If the tests are normal and there has only been one episode of syncope, it is considered a single, benign episode, which generally ends the evaluation (Gauer, 2011). However, if there have been multiple episodes of syncope taking place, more evaluation may be needed.
Frequent episodes can be troubling, and a diagnosis may be made through a Holter or event monitor, or through an implantable loop recorder. The loop recorder is generally used for infrequent but recurring episodes, while the Holter monitor is used for more frequent episodes (Ruwald, 2014). Both options can work well, and both will provide information when an event occurs that can help doctors determine the cause. If the monitor or loop recorder returns a normal sinus rhythm with symptoms, the evaluation is complete from a cardiac standpoint. However, if there are arrhythmias seen with the symptoms, treatment for the arrhythmia will be needed (Ruwald, 2014).
However, there is more to what can cause syncope than just heart issues. If they are ruled out completely through the testing required, lab work can also be ordered that will check iron levels and other issues (Ruwald, et al., 2012). That, coupled with blood pressure readings to determine if the patient simply has low blood pressure, can show other reasons the episode of syncope occurred. One of these reasons could be anemia, since it can strongly affect whether a person is getting enough iron-rich blood to the brain and other areas. Without enough iron, a person can become weak and fatigued, which could lead to syncope (Freeman, 2011). The CDC notes that syncope is a common hematologic manifestation of a lack of vitamin B-12, which can result in anemia (Manifestations, 2009).
A person's vitamin B-12 level can be low without hematological signs of anemia appearing, but most people who have low B-12 levels will show anemic signs such as pallor, fatigue, dizziness, and fainting (Manifestations, 2009). There are also vascular manifestations of B-12 deficiency that are seen in some people, including a greater risk for heart disease and stroke. Whether or not diagnostic testing reveals a cardiac reason for syncope, checking B-12 levels should be part of the evaluation for a syncope patient.
Management for a patient with syncope depends strongly on the reason for the fainting. For benign, single events, an evaluation and medical clearance may be all that is necessary (Freeman, 2011). These patients may never again experience an episode of syncope, but would need further investigation if they have more episodes. Outside of an evaluation to rule out any serious medical conditions that may have caused their syncope, these patients' only management plan is to self-monitor and report any more episodes, if they do occur. Patients in this situation may also be frightened and may benefit by talking to someone about their experience, but most accept it as a benign event with medical reassurance.
For patients with syncope caused by cardiac events, a management plan will include both the management of their cardiac condition and further diagnostic testing on a schedule assigned by their medical professional (Gauer, 2011). Medications to address heart rhythm problems can reduce arrhythmias that lead to syncope. In some cases, other treatments such as stents…