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Breast cancer treated surgically, throat cancer treated with surgery and radiation. Feeling dizzy. Any suggestion?

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48 yr old white Female, runner, physically fit not overweight. In last 12 months has had breast cancer treated surgically, throat cancer treated with surgery and radiation, hysterectomy (benign mass in uterus). Recent dizzy spells and subsequent Holter monitor showed sequential non-conducted P waves, pacemaker installed a week ago, all other cardiac tests show her heart is in excellent shape.

We thought this would stop the dizzy spells but she had another this morning (about a "5" on scale of 1 to 10, previous spells were as high as a "9"). She describes them as follows: "sudden sharp pain in middle of chest just above xyphoid, followed by what feels like a rush of blood up her chest and up the back of her neck". The PM clinic says the PM is working perfectly so what she's feeling is unrelated. Her GP isn't listening. Her drivers license has been pulled and she's starting to slide into depression. Any suggestions on what could cause these symptoms? Thank you.
Posted Fri, 27 Jul 2012 in Cancer
Answered by Dr. Anil Grover 2 hours later
Thanks for writing in.
I am a qualified cardiologist and read your question with diligence.
Let us separate the problems of dizzy spells and pacemaker insertion.
I believe the pacemaker clinic when they say that pacemaker is functioning normally. I am assuming they would have given her dual chamber pacemaker (DDD) that means the problem of non conducted p waves was only partly responsible for spells. As you have aptly put no longer 9 over 10 spells but still gets 5/10 spell. Therefore, we have to look for additional cause(s) for these spells. What immediately concerns me is occurrence of pain during spell. If you can go back to the doctor who must have been a cardiologist (In the US in some states only cardiac surgeons give the pacemaker) he can reprogram the pacemaker if need be and do a Holter again. In fact in most of the pacemakers you can look back through pacing system analyzer and find out the EKG at the time of spell. But if that shows only paced beats that will not help hence the need to temporary reprogramming of the pacemaker may be needed. That way we will get her normal EKG during spell showing her normal rhythm and other changes if any. That may indicate that heart is still the culprit- for example it shows changes due to decreased coronary blood supply during a spell which is getting now. A possibility of coronary artery disease, in a post radiotherapy patient can not be easily excluded. If heart is not the culprit then other causes of dizziness that is related to Ear(Benign Positional Vertigo) , Vertobasilar insufficiency(VBI insufficient blood supply to brain because vertebral artery is compressed) due to cervical spine problem and central vertigo(Brain stem dysfunction) need to be considered and excluded. All these conditions are treatable by simple means. Her depression is a natural consequence of the series of diseases she is suffering. She deserves our full understanding and empathy. I am sure once these dizzy spells are controlled she will get her license back. If she has conquered cancer she will ultimately win her here also.

If you have a further query please write back I will be most happy to answer.

With Best Wishes.

Dr Anil Grover,
M.B.;B.S, M.D. (Internal Medicine) D.M.(Cardiology)
http://www/ WWW.WWWW.WW
Above answer was peer-reviewed by
Follow-up: Breast cancer treated surgically, throat cancer treated with surgery and radiation. Feeling dizzy. Any suggestion? 3 hours later

Thank you VERY much for your speedy response.

You are correct that she was given a dual chamber pacemaker (Medtronic Revo MRI specifically). All the other cardiac tests showed her heart was 100% good. No signs of coronary artery disease or MI. Finding the heart block was the silver lining to all this since it probably saved her from dropping dead from heart failure one day. She had several of the spells while wearing the Holter monitor so I think they got good readings of her EKG during the spells. The PM was installed one week after the Holter test.

How is VBI diagnosed and treated? I've said all along that it sounds like a compressed nerve or artery that is causing these spells.

Thanks for your help and input.
Answered by Dr. Anil Grover 39 minutes later

Thanks for appreciating quick response, that is training in cardiology seconds are precious.

When you say 100% correct do you mean :
a. All the beats were paced atrial and paced ventricle and rate was in between preset Hi rate and lo rate.

b). Or atrial and ventricle pacing and sensing was normal, meaning thereby, some beats were of her own.

Reason is in situation a: All beats would show Left Bundle Branch Block as venticular lead (lower chamber lead) is placed in right ventricle, so this is stimulated first. In such a situation, diagnosis of coronary artery disease(CAD) or saying that there is no CAD is always dubious.
b: When some beats are normal (her own) there is no doubt left to say either way akin to situation in normal EKG.

So, if b existed there is silver lining of having much less chances of CAD but situation is iffy if it was a. So, please check with your doctor that he is satisfied in what he said or if he would reset hi and lo rate for a day and put her on Holter to get a her own impulse generated EKG. This is small but important point I was trying to make in my first response.

VBI is suspected on cervical spine x-ray by seeing inter vertebral bones space and osteophytes arising from vertebra, these osteophytes put pressure on vertebral artery. Diagnosis is almost confirmed on cervical spine MRI or almost 100% cofirmed/excluded on CT angio of vetebral vessels (the vessel supplying the area which causes central nervous system originating giddiness) in fact this area is concerned with balance while we are moving or suddenly change posture. Verterbro Basilar Insufficiency means compression of vertebral arteries from left and right side of neck which join together to form basilar artery which is inside skull supplying brain stem.

If you have any more question, I shall be happy to answer otherwise you can close the query with comments.

Best Wishes


Dr Anil Grover,
M.B.;B.S, M.D. (Internal Medicine) D.M.(Cardiology)http://www/ WWW.WWWW.WW

Above answer was peer-reviewed by
Follow-up: Breast cancer treated surgically, throat cancer treated with surgery and radiation. Feeling dizzy. Any suggestion? 2 days later
Thanks again Dr. XXXXXXX

Her situation was b) as outlined above, so silver lining. But the "spells" continue to happen.

On top of everything else, last night she had a seizure which she's never had before so things are going from bad to worse. Guess it's going to take some serious testing to figure out what's going on. XXXXXXX

Take care,
Answered by Dr. Anil Grover 2 hours later
You are right XXXXXXX it was a silver lining.
I guess, we doctors have failed you in not thinking out of box. It is the training universally taught XXXXXXX Try to explain, all the symptoms patient has with one disease.. XXXXXXX Exceptions occur. She is one living example being let down by us. I am sorry. Let us hope that we hit the diagnosis soon. Let wisdom pervail in the treating doctors.

All the best. Do let me know personally YYYY@YYYY

And please do not give up, she has done it before and came out as winner every time. Regards.

With Best Wishes.
Dr Anil Grover,
M.B.;B.S, M.D. (Internal Medicine) D.M.(Cardiology)
http://www/ WWW.WWWW.WW
Above answer was peer-reviewed by
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