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Melanie Cole (Host): Syncope is a transient loss of consciousness and muscle tone, and it’s important to understand the difference between cardiac and non-cardiac causes of syncope. My guest today is Dr. Aarti Dalal. She’s a Washington University Pediatric Cardiologist at St. Louis Children’s Hospital. Welcome to the show Dr. Dalal. What is syncope?

Dr. Aarti Dalal (Guest): Hi Melanie, thank you for having me. I think you did a great definition. Syncope really is the transient loss of consciousness and postural tone with spontaneous recovery. People typically describe it as fainting or passing out. It’s associated with temporary hypoperfusion or insufficient blood flow to the brain. I think what we do know is that syncope is quite common. It’s reported in up to one-third of the population, and it accounts for a significant number of both pediatric and adult Emergency Room visits.

Melanie: Do we know what the most common causes are?

Dr. Dalal: There are lots of causes of syncope. I think number one, it’s most important to remember that syncope actually is a symptom and it’s not a disease. When you understand that then you can start thinking about the different causes. Syncope can be something as benign as just passing out because, for example, we were standing upright for too long in a hot room, or we didn’t have enough to eat, and maybe our blood sugar is a little bit low. There can also be pretty significant and serious causes of syncope, and those are the cardiac causes and the things I’d really like to stress today.

Melanie: Before we even get to those cardiac causes, something like orthostatic hypotension --something that even adults and children can experience -- for a parent, this has got to be a really scary thing when a child experience syncope. Is it something that requires emergent medical care?

Dr. Dalal: Great question. I think you hit the nail on the head, which is syncope is scary. It’s scary for the patient but even scarier for the family member, or the parent that is watching their child fall to the ground. The first thing to understand is that common faint, or that vasovagal syncope which you identified is something that is not life-threatening. It can be scary for the family, and the patient and the patient might get hurt if they fall and hit their head, but the faint itself – that syncopal episode is not life-threatening. I think it’s important to understand how those patients might present. For example, the common, benign faint usually presents with a prodrome, so for example, they might have dizziness, or nausea, or some vision changes before they pass out, or these patient give a really good history of just not feeling well before they pass out. Typically, these events occur at rest or positional, and they give a great history of, “I was standing in a hot room – for example, I was at church, and I just felt really faint and then passed out,” or “I saw blood, and I passed out.” In those situations, those are not examples where I would recommend they rush their child to the Emergency Room.

Melanie: So those presyncopal sensations and if they just simply faint, but they were able to voice the reasons – the hot room, the blood – those are not quite that emergent, but if it just happens, when is it emergent.

Dr. Dalal: Again, very good question. The time that I get concerned about syncope is when they lack a prodrome, meaning it just happens all of a sudden, or the events are triggered by either exertional stress or emotional stress. For example, if they were exercising and during exercise they passed out, or they remember being very anxious or angry and they pass out, or if it’s associated with other cardiac concerns or symptoms – for example, palpitations -- those are situations that would make me worry.

Melanie: So if a Pediatrician sees a child in their office, what would you like them to do as their initial assessment?

Dr. Dalal: I think the first thing to understand about the syncopal event is one, the situation in which it occurred, so understanding the state of the activity of the patient. Were they at rest? Did they move from a seated position to a standing position? Were they standing for a long time? Or did it happen during activity? For example, if the patient was running and they said, “I was running at peak exercise, and I just passed out,” or if they give a history where the patient says, “I have this seizure history that is not controlled with my medication, and I pass out every time I get really angry, or anytime I’m really anxious.” Those are stories that I would want that patient referred to me. Another big thing is family history, so asking those right questions. Family history can be so telling in a patient. If they ask a question about family history, and they get a family member that has died suddenly at a young age -- less than 50 -- or if there was family history of a drowning or a near drowning event, or a syncopal car accident, or a family member that has seizures that again, is unexplained, or a family member that has a pacemaker or defibrillator, or a family member that was born deaf. All of those things, when you piece them together, they indicate that the syncope is not just your benign faint, but may be indicative of something more serious, a cardiac cause of syncope.

Melanie: So to actually pinpoint the cause, and as a Pediatric Cardiologist, then what is it that you would do next as far as the diagnosis?

Dr. Dalal: When we see a patient, or when a patient has been referred to me for syncope, I ask all of these questions. The first thing I really try to understand is what the patient was doing when they had a syncopal event. The second thing I do is I always ask a really detailed family history, and after I get that information, I can do additional testing. That might be something like an electrocardiogram, or an EKG, and an echocardiogram. Those things allow me to get a good picture of both the structure and the function of the heart and also the baseline rhythm. If this happened during exercise, I might also have the patient do an exercise stress test so I can see what their rhythm is doing during exercise.

Melanie: What about a Holter Monitor? Is that ever required?

Dr. Dalal: A Holter Monitor and, or an event monitor are both great tests as well. Essentially what a Holter Monitor allows me to do is I can see what the patient’s rhythm is doing for a full 24 hours. An event monitor is a little bit different in which the patient wears the monitor for an extended period of time, and if they have events that don’t occur every day, they can push the button when they have an event, which allows me to correlate a rhythm with their symptom.

Melanie: And that would help you rule out something else like a seizure disorder?

Dr. Dalal: Exactly. What these tests really allow me to do is to make sure that there isn’t a cardiac cause because although -- when we talk about it, it may seem that this is very black and white. A lot of times it's very gray, and you don’t exactly have the best history, and you’re not exactly sure of the situation in which the syncope occurred, so these tests allow me to help rule out dangerous causes of syncope to make sure that it isn’t an arrhythmia or a cardiac-related cause.

Melanie: And what do you do for the child and what do you say to the parents to reassure them and give them some hope about this?

Dr. Dalal: Sure, so I think the first thing is, if it is benign syncope, which most often it is, it’s important for the family to realize that it will get better. Doing things like increasing fluid intake, specifically water, and non-caffeinated beverages, is actually very helpful, and then adding salt to the diet, or sometimes we can prescribe medications. If it is benign syncope, that will get better. If it is something that I’m more concerned about, we do have a lot of treatment options, and usually, that requires medications, sometimes different devices, but the important thing is, is getting the patient and the family diagnosed. At St. Louis Children’s, we have a really good team that can help support the family and make sure that they are getting the appropriate care.

Melanie: And Dr. Dalal, what do you do if you figure out it’s a psychogenic syncope? If it’s something in an adolescent, or it’s something that’s happening in terms of emotional stress or times of anxiety, then what do you tell the parents?

Dr. Dalal: That’s a great question because it actually is a large portion of the patients that I see that are referred to me. Psychosomatic or psychogenic causes of syncope are quite common, and I think it is important that the family realizes number one, that it is real to the patient. Trying to make the patient feel like this isn’t real is not the way to go, but helping them understand that sometimes finding out the reason, or the root cause of the anxiety, or whatever the stress is that’s causing them to have the syncope, number one, is important. And then two, making sure we offer support in that way. That can include referring the patient to a psychologist or a psychiatrist and sometimes even starting anti-anxiety, or anti-depression medications.

Melanie: And when would you like a Pediatrician to refer to a Pediatric Cardiologist?

Dr. Dalal: I would love if a Pediatrician would refer the patient to me when they start to hear these red flags. When they get a history where there’s a minimal prodrome or the patient has recurrent syncope -- anytime you have recurrent syncope, I think it’s warranted to ask more questions or get more help and I’m happy to see those patients -- or if the triggers are related to exercise, or emotion, or there’s a family history, those are really big things. Obviously, if anybody ever required any significant intervention, like they needed CPR, please send those patients to me [LAUGHS].

Melanie: And tell us about your team. Why is St. Louis Children’s Hospital so great to work with?

Dr. Dalal: Here at St. Louis Children’s we have a huge number of Cardiologists, but also within our group there are three of us that are dedicated to rhythm disturbances. We have an electrophysiology team of three Cardiologists and a Nurse Practitioner that is focused on inherited arrhythmias and conduction disorders. Within our group, there are lots of Cardiologists that are dedicated to children who have these concerns, and I think we work really well as a team. We’re supported by a multidisciplinary team as well, where if you end up coming and you are diagnosed with an inherited arrhythmia, we work with both a psychologist and a genetic counselor that make sure that not only the patient but the family is well-supported.

Melanie: Thank you, so much, for being with us today, Dr. Dalal. Dr. Aarti Dalal sees the patient at both St. Louis Children’s Hospital off King’s Highway in the Central West End and St. Louis Children’s Hospital Specialty Care Center in West St. Louis County. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital, and for more information on resources available at St. Louis Children’s Hospital, you can go to StLouisChildrens.org, that’s StLouisChildrens.org. This is Melanie Cole. Thanks, so much, for listening.