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    Treatment for sleep apnea syndrome and syncope

Posted on Fri, 28 Feb 2014 in Hypertension and Heart Disease
Question: Hello I am 43 yrs old female. 4 yrs back i had syncope and few months back twice. In all the cases fainting happened immediately after climbing and getting down the stairs or if i am walking fastly feel like falling down. I thought because i am suffering with cervical spondilities fainting has happened but orthopedic doctor has confirmed that my cervical pain is not so severe to cause fainting. In between I had high BP level going upto 170/90 so consulted Cardiologist who has taken 2D Echo (normal), Holter study (normal) subsequently doctor made me walk on TMT for few minutes and immediately ECG was taken and prolonged QT problem has came out. Earlier two times also prolonged QT problem has come but no medication was taken. Now, doctors have suggested (Dr XXXXXXX D XXXXXXX Dr.C.Narasimhan and Dr.Rajsekhar) for implantation of automatic cardioverter defibrillator. They have prescribed Concor 5 mg tablet later on increased to 7.5 mg. Sleep study was conducted and 106 apneas were identified. so I have taken onemore opinion i.e. from Dr XXXXXXX XXXXXXX Sr.Cardiologist Apollo Hospitals, Secunderabad. He asked me to consult chest physician first. I have consulted Dr.R.Vijaykumar, he says my chest x-ray is perfect and he suggested to use use CPAP machine for sleep apneas which i am using now. Chest physician has clarified that sleep apneas does not have impact on my fainting episodes.I have informed this to Dr XXXXXXX XXXXXXX Dr. XXXXXXX XXXXXXX asked me to use CPAP and come for review after 3 weeks. I asked him i will be using CPAP during night times whereas i am having problems during day time, then he said, your faintining episodes have no relation with prolonged QT intervals and says that ICD is not recommend as there doestn't see any serious problem with prolonged QT intervals and asked me use Concor tablet 2.5 mg daily. Now i am using Concor 2.5 mg daily but since past three days pain is there is chest left side when consulted Dr XXXXXXX XXXXXXX with ECG (day before yesterday again prolonged QT problem - report not attached) Dr XXXXXXX XXXXXXX suggested if I wish to go for ICD he is ready to implant ICD. Now i am delimma whether going for ICD is recommended or not? pls. suggest.
Answered by Dr. Sukhvinder Singh 5 hours later
Brief Answer: Please provide more details. Detailed Answer: Hi, Thanks for your query. 1. Your sleep study shows that you have sleep apnea syndrome and require therapy. I hope you will get lot of relief from CPAP, which you are currently using.. 2. Second aspect is syncope. I would like to know more about your problem in this regard. A. If you can tell me what is the highest QTc which has been recorded in your case? B. If you can upload ECGs showing the longest possible QTc? C. Can you detail me about the episode? How long they lasted? Could someone check your pulse at those times? Did all episodes were precipitated by using stairs? How you got consciousness back? Was some kind of resuscitation given to you? What was it and what was opinion of rescuers. Can you upload the ECGs of your TMT exercise phase? D. If at all you have ever been shown to have polymorphic Ventricular tachycardia documented on ECG. E. If you have undergone coronary angiography and electrophysiology study ever? I know these details will require a bit of effort on your part but are important in understanding the need of ICD in your case. Sincerely Sukhvinder
Above answer was peer-reviewed by : Dr. Raju A.T
Follow up: Dr. Sukhvinder Singh 8 hours later
Good Morning Doctor 1, Can pls. let me how many days i have to use CPAP. 2. Highest Qtc noted was > 510 mS,QTc > 490 mS ( after 2nd syncope) and >460 mS (ECG dated 23rd Dec.2013 after 3rd syncope, TMT-report already attached) 3. Unconsciousness lasted for 1-2 minutes, in one case rescuer told the pulse was fast, some foam like liquid, very little came out of the mouth (in 2nd syncope) this happened in temple. in other cases not one checked the pulse, these episodes happened in train. Yes all the 3 syncopes happened after climbing the stairs and immediately after getting the stairs, i am having similar problem now also i try to go up and down the stairs, trying to avoid such situations. Nothing was given to me for making me conscious, as per the rescuers i came back to consciousness on my own. Doctor, i have similar problem while trying to climb or get down the stairs, trying to avoid such situations. 4. No idea. Polymorphic ventricular tachycardia is not mentioned in text form in my ECG. 5 coronary angiography and electrophysiology study was not done. Pls. suggest further. thanking you XXXX
Answered by Dr. Sukhvinder Singh 16 hours later
Brief Answer: Please see details. Detailed Answer: Dear Ma'm 1. The CPAP is required to be taken life long, unless something changes your sleep apneas dramatically which may include weight loss, good control of thyroid status and abstinence from alcohol (where patient uses alcohol). This therapy is effective only for the duration in which it is taken. 2. The QTc of 510 ms is significant but there are certain important things which need to to be clarified. ICD is justified if there is a family history fo sudden cardiac death in blood relative known to be caused by prolonged QTc or unknown cause. It is justified if during any of syncopal attacks Ventricular tachycardia was document. If ventricular tachycardia was never documented or demonstrated in your case, then presence of only a QTc of 510 ms is not a strong indication for ICD. Did they ever tried to provoke tachycardia in laboratory by exercise/ auditory stimuli or psychological stress? Usually (but not always) the tachycardia causing syncope will be pulseless or with feeble pulse and not likely to terminate on its own in few seconds. Going for ICD without this information will have two disadvantages a. You may continue to have syncope despite ICD if VT is not the reason for syncope. 2. You may have an unnecessary procedure. 3. I required your TMT films to ascertain your QTc myself before and during exercise. I have already seen the report. 4. If you are receiving any medications beside thyroid disorder? What is your height and weight ? Hope it gives you some insight into the ICD issue and help in framing more questions. Waiting for your reply. Sincerely Sukhvinder
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Sukhvinder Singh 14 hours later
Good Morning Doctor i dont have any idea about Ventricular tachycardia in the reports. 1) In mar.2013, ECG was taken wherein 510 ms QTC was recorded subsequently TMT was taken. 2) Again in Oct.2013 ECG was taken prolonged QT was noticed. 3) In Dec.2013 Dr XXXXXXX Nagaranjan made me walk on TMT and took ECG which recorded borderline prolonged QT > 460 ms - Doctor suggested for ICD. 4) In XXXXXXX Dr.Narasimhan asked to take 12 lead TMT with early recovery, with medication (5 mg concor tablet was taken before tmt) Conclusion for 12 Lead TMT: Test is terminated due to giddiness.No significant ST-T Changes seen during exercise with low work capacity (4.6 mets) & HR 107 BPM (60% THR)- Doctor suggested for ICD because of Genetic problem and 3 syncopes. 5) Dr.Rajsekhar seeing all these reports suggested for ICD. 6) Dr XXXXXXX XXXXXXX asked to use tablets for few days and suggested for CPAP. Due to pain in chest few days back ECG was taken which recorded prolonged QT 519 ms Some error is coming while attaching reports. I didnt use any medication apart from Thyrowel that too for few months only. Stopped using in XXXXXXX 2013 since thyroid was under control. Stil thyroid is under control. My weight is 90 kgs, height: 146 cm, BMI 42.4. Pls. advise further doctor Thanks XXXX
Answered by Dr. Sukhvinder Singh 7 hours later
Brief Answer: please see details Detailed Answer: Dear Ma'm 1. Your ECGs of TMT show prolonged QTc but it does not increases with exercise. Your basal ECG also show a QTc of ~505 ms. 2. In your case we have syncopal attacks, we have prolonged QTc but it is not conclusively proven that you have syncope due to prolonged QT interval (via polymorphic ventricular tachycardia; a rhythm disorder of heart induced by prolonged QT). 3. I suggest you to have a second opinion from an electrophysiologist. Since your symptoms are exercise related you should be subjected to exercise stress test in controlled conditions and if you have marked reproducibility of symptoms without any ventricular tachycardia, then possibly QTc prolongation is not the culprit. This should be done by an expert in non-invasive cardiology in consultation with an electrophysiologist. Sincerely Sukhvinder
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Sukhvinder Singh 57 minutes later
Good Evening Doctor. I have taken opinion of 4 doctors so far. 3 of them are good electrophysiologist who have suggested for ICD. Other one is Sr.Cardiologist in Apollo has finally concluded for ICD recently. Keeping aside syncope issue, pls. let me know will prolonged QT will cause sudden death. as per my ECG records, do you see any serious issue to be treated. I am using Concor 2.5 mg tablet now even then QT prolongation is there. What could be the reason for QT prolongation since past few years. Pls.reply. thanks XXXX
Answered by Dr. Sukhvinder Singh 1 hour later
Brief Answer: please see details Detailed Answer: Dear Ma'm 1. QT prolongation may be since birth (congenital) which has been noted recently. It may be due to use of certain drugs, liquid protein diets, head injury, electrolyte imbalance (low calcium , low potassium, low magnesium) etc., which possibly has been ruled out by your electrophysiologists. 2. Yes, prolong QT interval can be a cause for sudden cardiac death. As I said earlier that your QT is definitely prolonged but I could not establish a direct link between syncope and prolong QT with the current information. Concor (bisoprolol) a beta-blocker is given to patients with congenital prolonged QT syndrome. It tends to produce balance between sympathetic and parasympathetic arms of automonic nervous system; the dis-balance between the two has been touted as a mechanism for sudden cardiac death in long QTc syndrome. Different beta blockers decrease it to different extent and if one agent fails the other one may be tried. Sincerely Sukhvinder
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Answered by
Dr. Sukhvinder Singh


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