Malignant Vasovagal Syncope
A 62-year-old man without significant medical history presented to his doctor with repeated episodes of syncope. The episodes were always associated with micturition (often at night) and had caused falls resulting in head injury. His wife was particularly concerned, noting that he became apneic while sleeping. He was diagnosed with sleep apnea. A 24-hour Holter monitor was obtained as part of the syncope evaluation. While wearing the monitor, he awoke in a panic, feeling that something was very wrong, and he came directly to the emergency room. He was evaluated in the emergency room and was told he was fine. The patient insisted, however, that the Holter monitor be reviewed before he left the hospital. The Holter monitor displayed 8 asystolic pauses, including 1 pause of 21 seconds and another of 35 seconds, at which point he awoke abruptly (Figure). The etiology was felt to be malignant vasovagal syncope. On the basis of these results, he was admitted to the hospital and a dual-chamber pacemaker was placed. At 18 months of follow-up, the patient reports no more episodes of micturition syncope. He uses the pacemaker only 2% of the time. He has greater energy, and his wife reports that the sleep apnea is gone.
This research was conducted while Dr Glatter was a Pfizer/Society Women’s Health Research Scholar.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.