Vasovagal Syncope and avoiding a pacemaker

Ever trained anyone who faints when the room temp changes?
My housemate (female 23yo 5'2" 48kg) has been struggling with vasovagal syncope for the best part of 8 years now. It would not be uncommon for her to faint once or more times a week. Temperature changes, high stress events, stimulants and rapid change in exertion all result in nap time.
It goes without saying doctors have advised avoiding strenuous exercise at all cost. She runs, squats and deadlifts none the less, not dead yet. They have also proposed a pacemaker may be her only out.
It seems logical to me that a stronger heart could only do good things.
Thought it worth seeking a professional opinion, maybe someone on here could help her find a path to a more function life.

Thanks for any help!

A pacemaker? For vasovagal syncope????

You can have a cardiodepressive version of vasovagal syncope, where the heart rate drops out....but it’s pretty darn uncommon. Unless they’ve documented it on a tilt table test (or cardiac monitoring of SOME sort), she doesn’t have that and doesn’t need

I guess if she has had an event recorder demonstrate genuine bradycardias associated with the loss of consciousness and it is happening as frequently as you mention then there may be no other choice. However why this means no strenuous exercise is beyond me.

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Originally Posted by Mark Rippetoe

A pacemaker? For vasovagal syncope????

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Yeah. That's exactly my response. Something else is going on.

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Originally Posted by Jdcuth

I guess if she has had an event recorder demonstrate genuine bradycardias associated with the loss of consciousness and it is happening as frequently as you mention then there may be no other choice. However why this means no strenuous exercise is beyond me.

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Yeah, we're talking in a vacuum here. "Vasovagal" is a wastebasket term. It basically means the syncope is neurocardiogenic....like most syncope. But sometimes it's because of a malignant arrhythmia. As Simon intimates, she needs a tilt-table test and probably a holter and an echo. IOW, she needs to see cardiology. If she came to me, I wouldn't train her until I had that workup in hand.

I knew this girl once, a lab tech, with a similar presentation, which did not get worked up beyond the "oh it's just vasovagal syncope now go away" phase. Turns out she had a Brugada variant. Sudden cardiac death in the lab one day while working at the bench. Fortunately across the street from our ED. Resuscitated in less than 15 minutes with a fair neuro outcome, and got an ICD. Happy ending. Could have been...worse.

Remember: syncope is a condition in which your brain temporarily stops working for some reason. Respect that, and get to the bottom of the "some reason" part. That's the role of a doctor who gives a shit and doesn't just slap a "vasovagal" diagnosis on a young person with recurrent syncope.

I really need to stop being imprecise in my replies.

Syncope is loss of blood pressure to the head, for whatever reason, that lasts long enough for you not to be able to
stay conscious (or at least upright). If. I remember aright, it will happen to about 10% of us during the course of our lifetimes.
Most of the time, we never figure out what it was, and it goes away.

There are red flags to watch out for, but one noteworthy thing about your friend is that she hasn’t died from any of these multiple
episodes. That all but rules out most of the more terrifying causes. I’d be interested to know what they know about her syncope, before
they start putting hardware into her.

If nobody has documented a pause in her heart rate of more than 3 seconds, or SOME sort of bradycardia at the time she passes out, then
they shouldn’t even bring up the word pacemaker.

Thankyou for your reply.
Sorry i should have been more informative.

She has been diagnosed with cardiodepressive vasovagal syncope. She was diagnosed via the tilt table test. She does see a cardiologist. No arrhythmia.
During an episode her heartrate ramps up to +140ish before dropping to 40bpm and thus inducing the faint. At least that is what was recorded on the table. Her resting bpm is usually around 70.

In that scenario I suspect she does need a pacemaker. I’m no expert in cardiology but I can’t think of another way to prevent the profound bradycardias she is getting and frequent fainting would be quite an unpleasant symptom to suffer I hope she gets somewhere

Ah, then that’s simple. Pacemaker. It will greatly improve her quality of life.

I mean, there’s other stuff (making sure she’s hydrated, etc), but if she’s failed that, then this is a no-brainer.

The vast majority of the time, the pacemaker will just sit there and watch the world go by. It will only leap into action
If she goes low.

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Originally Posted by simon0596

I really need to stop being imprecise in my replies.

Syncope is loss of blood pressure to the head, for whatever reason, that lasts long enough for you not to be able to
stay conscious (or at least upright). If. I remember aright, it will happen to about 10% of us during the course of our lifetimes.
Most of the time, we never figure out what it was, and it goes away.

There are red flags to watch out for, but one noteworthy thing about your friend is that she hasn’t died from any of these multiple
episodes. That all but rules out most of the more terrifying causes. I’d be interested to know what they know about her syncope, before
they start putting hardware into her.

If nobody has documented a pause in her heart rate of more than 3 seconds, or SOME sort of bradycardia at the time she passes out, then
they shouldn’t even bring up the word pacemaker.

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Yes, this should definitely be worked up and characterized before putting in a device, but I would just add that dying from the syncope itself is not the only concern. Regardless of the cause, sudden loss of consciousness can be a big problem if you are driving, swimming, holding a baby, rock climbing, etc. Not to mention it's a bummer to have an ambulance called on you unnecessarily every time you drop in the grocery store or mall. Fainting 2/week puts a huge crimp in your lifestyle. So even if it's "benign," it needs treatment. Whether a pacer is needed is another story. Pacers are pretty darn expensive, so I would assume that at the very least the insurance company is insisting on proper eval and perhaps trial of other treatment first, even if the doctor is a pacer-happy cowboy who drives a Bentley with a "MEDTRONIC" vanity plate. But maybe I shouldn't assume these things...

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Originally Posted by jfsully

Yes, this should definitely be worked up and characterized before putting in a device, but I would just add that dying from the syncope itself is not the only concern. Regardless of the cause, sudden loss of consciousness can be a big problem if you are driving, swimming, holding a baby, rock climbing, etc. Not to mention it's a bummer to have an ambulance called on you unnecessarily every time you drop in the grocery store or mall. Fainting 2/week puts a huge crimp in your lifestyle. So even if it's "benign," it needs treatment. Whether a pacer is needed is another story. Pacers are pretty darn expensive, so I would assume that at the very least the insurance company is insisting on proper eval and perhaps trial of other treatment first, even if the doctor is a pacer-happy cowboy who drives a Bentley with a "MEDTRONIC" vanity plate. But maybe I shouldn't assume these things...

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This. Also, if it were me I'd consult with an electrophysiologist. Not my wheelhouse, but I'd want to know if there was a prospect for ablative therapy before somebody put a fucking Gameboy in my chest.

Oh, sure. I’m already operating under the assumption that the syncope itself isn’t going to off her. I’m just saying, if this is as advertised, then pacer is the logical choice

I think she needs to gain about 20 pounds of bodyweight. She's not very "robust," and it usually helps with frailty.

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Originally Posted by Jonathon Sullivan

This. Also, if it were me I'd consult with an electrophysiologist. Not my wheelhouse, but I'd want to know if there was a prospect for ablative therapy before somebody put a fucking Gameboy in my chest.

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Can’t ablate something that isn’t there. Bradyasystole isn’t an arrhythmogenic focus or an accessory pathway.

Agreed, but I haven't seen a rhythm strip or EKG on this lady yet. I'm not sure I accept the diagnosis.

‘Ablation before Pacemaker’ in a patient with bradycardia: a case report | QJM: An International Journal of Medicine | Oxford Academic

I would be fairly sure if she’s under a cardiologist they’ve looked for a potentially treatable cause- how far they go down a full electrophysiological study is down to them. But in the absence of a reversible cause for the bradycardias a PPM could be the best treatment and is a VERY low risk procedure for someone who sounds young with no co morbidities. My point is that it is by no means a ludicrous option, but should not be undertaken lightly.

Just as an anecdote, my sister was troubled with wolff-Parkinson-white picked up after pregnancy and was getting semi regular tachycardias and had an ablation planned. She started to lose weight before the procedure and utilised some weight training as part of it. The tachycardias disappeared and I’ve always wondered if frequent valsalva manouveres during lifting could have contributed to the problem resolving.