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Have vaso-vagal attacks. On electrolyte. Have vomiting, over heating, low BP. Ask for temporary pacemaker?

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Cardiologist, Interventional
Practicing since : 1996
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Vaso-vagal at 0000 if I go to sleep. I drink water, a litre an hour with electrolyte replacements, and walk around. Can take no food or alcohol. On the ground I have vaso vagal attacks if I take strong pain killers, vomit, get overheated.
On planes when it begins I quickly go to a cold toilet, splash my neck, face, torso with cold water fast, lie on the floor on the pee and flotsom, with my legs up the wall. It takes about 5 minutes to begin feel that I will not die ignominiously in a toilet. I have only once taken my pulse, in the neck, 8 beats per minute. I can walk around (though not stand still for long) and work at 60/40 and I know that my blood pressure is much lower than that during one of these attacks.

15 years ago a cardiologist said that he could arrange for me to have a pacemaker. I refused. I need to go on a 24 hour long haul flight which I will stop half wa to sleep. I am 74, and frightened. Is it reasonable to see a cardiologist and ask for a temporary pacemaker to cover the return trip?
XXXXXXX Hutchison
Posted Thu, 31 May 2012 in Hypertension and Heart Disease
Answered by Dr. Raja Sekhar Varma 10 hours later
Thank you for the query.

I understand that you have vasovagal syncopal episodes when you are on flights. I also see that you have other medical problems as you have listed.

The confirmation of your condition can be done by undergoing a head-up tilt table test. In addition to confirming the diagnosis, it will also be possible to classify the type of vasovagal episode that you are having. A cardio-inhibitory type of response will benefit from a pacemaker, but not a vasodepressor type.

A temporary pacemaker will not help you. To prevent a vasovagal response, you need a special type of dual chamber pacemaker with a rate-drop response. This is present only with certain types of permanent pacemakers. Also, it is very difficult to travel long-distance with a temporary pacemaker with the risks of bleeding from the site, infection, lead displacement, etc.

The following measures could help but they are not fool-proof.
1. Avoid dehydration.
2. Extra salt in diet.
3. Keep changing your posture and stamp your feet repeatedly.
4. Wear tight stockings which may aid in returning venous blood to the heart.
5. Careful use of beta blockers in consultation with your doctor. You will need a highly specific beta-1 blocker like bisoprolol or metoprolol (long acting).
6. Tilt training: You could do a formal tilt training under supervision and using a tilt table. You could also stand upright with feet close together against a wall. Start with a few minutes at a time. Gradually increase the time till you are able to do it for half an hour without symptoms. Keep cushions and supports ready in case you get symptoms.

I hope this answers your query. Feel free to ask me for any further clarifications.
With regards,
Dr Raja Sekhar Varma, MD, DM
Consultant Interventional Cardiologist
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