Friday, 29 November 2013

Fainting (Syncope) Treatments In conventional medicine perspective

Fainting also known as Syncope of "black out" is defined as a condition of sudden loss of consciousness followed by the return to full wakefulness in a short duration as a result of  abnormally low blood pressure. In most cases, it is caused by hypotension, with blood pressure that's lower than 90/60 mmHg.(1). Even though Low blood pressure has mainly been regarded as good health for people who exercise, but recent studies have indicated an association with depression in elderly people. there are epidemiological evidence for an association of low blood pressure with anxiety and depression, which is not caused by cardiovascular disease.(2). In some case, severely low blood pressure can seriously impair adequate blood flow to vital organs and a life-threatening condition called shock.
A. In conventional medicine perspective
1. Prehospital Care(60)
Acute care to someone faint must be taken to increase blood flow to the brain, such as with the legs raise, loosen all tight clothing, crossing the legs or squeezing the thighs together, etc. and call 911. The patient may require the below from the medical team.

a. Intravenous access
b. Oxygen administration
c. Advanced airway techniques
d. Glucose administration
e. Pharmacologic circulatory support
f. Pharmacologic or mechanical restraints
g. Defibrillation or temporary pacing
h. Etc

2. Medication
2.1. Beta blockers
a. Beta blockers or beta-adrenergic blocking agents, beta-adrenergic antagonists, beta-adrenoreceptor antagonists or beta antagonists are the most commonly used type of medication to prevent syncope, as a result of blunting of elevated catecholamine levels that precede vasovagal syncope. Dr. John R. Kapoor, MD, PhD at the Stanford University said "Notwithstanding the widespread use of beta-blockers in the past, some studies on chronic beta-blocker use have been less than encouraging and may suggest some benefit in older but not in younger patients, as mentioned in the recent article by Tan and Parry"(61). In other study group consisted of 62 patients (29 females, mean age 32.8+/-12.3 years and 33 males, mean age 35.9+/-18.2 years) with at least two syncopal episodes during the six months preceding positive tilt testing, propranolol administered intravenously prevents syncope during tilt testing in a significant proportion of patients. Both complete or partial efficacy of intravenous propranolol predict long-term efficacy of chronic beta blocker therapy in patients with vaso-vagal syncope.(62)

b. Side effects
Major cardiac effects caused by beta blockade include the precipitation or worsening of congestive heart failure, and significant negative chronotropy(62a) and severe and therapy-resistant rhinitis, sinusitis, and nasal polyp(62b)
and (62c)
* Nausea
* Diarrhea
* Bronchospasm
* Dyspnea
* Cold extremities
* Dizziness
* Hair loss
* Abnormal vision
* Insomnia
* Nightmares
* Sexual dysfunction
* Erectile dysfunction
* Etc.

2.2. Serotonin re-uptake inhibitor (SSRI)
a Antidepressants are commonly used in the treatment of depression, anxiety disorders, and some personality disorders. In the study to assess whether the well-tolerated serotonin re-uptake inhibitor paroxetine hydrochloride could prevent vasovagal syncope in young patients resistant to or intolerant of previous traditional therapies, Paroxetine significantly improved symptoms of young patients with recurrent vasovagal syncope unresponsive to or intolerant of traditional medications and was well tolerated by patients.(63). Other report indicated that the serotonin reuptake inhibitor sertraline hydrochloride can be effective in preventing recurrent neurocardiogenic syncope in selected patients unresponsive to or intolerant of other therapeutic modalities.(64)

b. Side effects (65)
Almost all SSRIs are known to cause one or more of these symptoms, including Sexual Dysfunction(66) and withdrawal syndrome(67), Suicide risk(68) and
* Nausea/vomiting
* Drowsiness or somnolence
* Headache (very common as a short-term side effect)
* Bruxism
* Extremely vivid or strange dreams
* Dizziness
* Fatigue
* Mydriasis (pupil dilation)
* Urinary retention
* Changes in appetite
* Insomnia
* Etc.
In rare case, SSRI antidepressants may cause cardiac effects, according to American Family Physician, 8/1/97 by Grace Brooke Huffman, but SSRIs are safe and do not have a high rate of cardiovascular adverse events. However, further study is needed to determine whether tricyclic antidepressants and SSRIs are equally efficacious in patients with cardiovascular disease.(69)

3. Surgical
Pacemaker implantation may be necessary for some patient because of either severity or do not respond to the medication to has been successful in decreasing the number of fainting episodes. Pacemaker implantation is a procedure to put a small battery-operated device into the chest to help the heart beating regularlyas it send out the regular electrical pulses. There is a report  on a patient with recurrent sleep syncope (with physical injury) in whom an asystolic pause was documented during one of her "sleep syncope" spells. Implantation of a dual chamber pacemaker (5-year follow-up) "cured" her of further syncope(70)
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