CME INDIA Case Presentation by Dr Deepak Gupta, DM, Card., Pulse Hospital, Ranchi.

CME INDIA Case Study:

(Case courtesy CSI-Jharkhand)

• 60 yr. female. c/o Recurrent syncope… CT brain normal. What’s next?
• Being investigated for last 15 days.
• Advised by neurosurgeon.
• MRI brain and cervical spine, carotid doppler, Echo, sodium and potassium.
• Holter showing  flat line/Multiple episodes of Syncope during monitoring.

CME INDIA Discussion:

Dr Venkatesh Molio, Maregoan, Goa: Suggestive of tachy Brady syndrome.Needs urgent permanent pacemaker and antiarrhythmic to tachycardia

Dr P G Sarkar, DM Card, Ranchi: As a part of sick sinus syndrome

Dr Deepak Gupta: Patient  attandant not convinced with diagnosis .they said it may be  related with diet as patient  recently taken advice form dietician and change the diet as advised . Went home .

Dr P G Sarkar: One fine day she will have cardiac arrest and then blame every doctor who has ever seen her 😅

Dr Sanjay Kumar, Cardiac surgeon, Ranchi: Echo too should be added

Dr P G Sarkar: 3 important things :

1. Asystole (either CHB or SSS) can lead to seizures

2. Seizures may cause various ictal or post ictal arrhythmias. 7 different patterns are described.

3. Many drugs commonly used to treat seizures, can exacerbate underlying SSS or AV nodal disease.

Dr Anil Kumar, Ranchi: Many such cases of syncopal attacks are of cardiac origin usually investigated for neurological disorders.Loop holter is must in such cases. Many other  investigationneeded like  tilt test, Coronary angiography etc besides EEG for half hour.

Dr Raju Sharma, Jamshedpur: Seizures also occur with intermittent VT!!

Dr D P Khaitan, Gaya: SSS with variable presentation on ECG –  to me this belongs to double nodal disease. Only to express that monitoring has revealed a variable picture of SSS including double nodal disease – that’s why the new nomenclature of STRUCTURAL NODAL DISEASE is used by so many.

Dr Deepak Gupta: This patient is having significant AV nodal disease also

CME INDIA Learning Points:

By Dr Deepak Gupta Ranchi, DM Card., Pulse Hosp:

1. Proper History of syncope is  very very important.
2. 1st and 2nd  choice of investigation depend on history.
3. It is true that many patient 1st report to  neurologist or neurosurgeon and get CT 1st.
4. Normal looking 12 lead ECG do not rule out cardiac cause.
5. Due to intermittent nature of conduction disorder ,many cardiac causes of syncope missed.
6. Sick sinus syndrome is likely diagnosis  and must be ruled out  in recurrent classical syncope  in age more than 60 even ecg is normal.

CME INDIA Tail Piece:

Dr P G Sarkar, DM Card., Ranchi: Posting ECG of a similar case

• 60yr male apparently on Rx for seizure disorder.
• Attendant describes LOC followed by tonic clonic posturing.Multiple episodes

Dr D P Khaitan, Sr. Consultant Physician, Gaya:

Findings:

• PR interval prolonged =0.22″ + Left postetior hemiblock ( frontal axis = +120 degree + C RBBB

= Trifascicular block.

• Possibly the patient might had passed to complete heart block intermittently  leading to Stokes AdamSyndrome.

* S1 Q3 T3 syndrome.

*  ST /T changes in inferior leads / V4-6.

Conclusion:

Stokes Adam syndrome –

• Possibly due to intermittent transmission to CHB from.trifascicular block.
• The explain of the other findings need detailing of the clinical findings.
• Left posterior hemiblock may be itself the cause of S1Q3 T3 syndrome.
• Other common pathological conditions which can cause S1Q3T3 electrocardiographic abnormality are pneumothorax, pulmonary embolism, cor pulmonale, acute lung disease, and left posterior fascicular block.

Dr P G Sarkar DM Card:

Right bundle branch block with left posterior hemi block with prolonged PR.. suggestive of trifascicular block.. with LOC pacemaker is indicated.

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