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Blackouts and Dizzy Spells

FOURTEEN

Blackouts and Dizzy Spells

Dr Nicholas P Gall

MSc MD FRCP

Consultant Cardiologist and

Cardiac Electrophysiologist

Secretary: IdaWhite

T: 020 7234 2263

F: 020 7234 2998

[email protected]

.

co.uk

www.gallcardiology.com

Dr Nicholas Gall is a

Consultant Cardiologist with

a subspecialty interest in

Cardiac Electrophysiology – the

management of heart rhythm

disorders. Dr Gall qualified from

Guy’s and St Thomas’ Hospital in

1993 and after general medical

training in London, joined the

South East Thames Cardiology

Training Scheme, gaining his

CCST in 2003. He has been

a Consultant Cardiologist

at King’s College Hospital

since 2004, with additional

time spent at Guy’s and St

Thomas’ Hospital (part of King’s

Health Partners). He is also an

Honorary Senior Lecturer at

the University of London.While

Dr Gall manages all aspects of

heart disease, his subspecialty

area is heart rhythm problems

including radiofrequency

ablation and device therapy

(pacemaker, ICD and CRT).

This area also includes the

prevention of sudden cardiac

death from inherited syndromes.

His particular area of interest

is in the management of

blackouts, dizzy spells and

related syndromes. This has

led to the development of the

Neurocardiology Service at

King’s, a joint venture between

the two specialties to better

manage patients crossing

between the two areas. He is

also Syncope Lead for the South

East Thames Cardiac Network.

Fits, faints, funny turns, dizzy spells; there

are almost as many terms to describe

such events as there are causes. In many

cases the diagnosis is clear. However,

sometimes the events are more difficult

to fathom. It is well recognised that many

patients are misdiagnosed, sometimes

being inappropriately treated for years.

This can obviously have a multitude of

follow-on effects, not least the side-

effects of medication, the stigma of a

diagnosis (particularly when inaccurate)

and the implications for driving and

occupation.

These events are common clinical

problems; perhaps 1% of all visits to

the Accident & Emergency Department

relate to variations on this theme

and the situation is very similar in

general practice. Furthermore, it has

been estimated that at least 10% of

unexplained falls in the elderly are

caused by syncope associated with an

element of retrograde amnesia.

The aetiology of these events can be

cardiac, neurological or psychological;

other events where consciousness

is altered, for instance with coma or

intoxication, make this area more

complex, often requiring close

collaboration between a number of

medical specialties. Recently (August

2010) NICE published guidance on the

management of this complex area under

the termTransient Loss of Consciousness

(T-LOC). International guidance is also

available from the European Society of

Cardiology, updated in 2009.

The diagnosis, while sometimes elusive,

can often be made from a detailed

history, a focused examination and simple

investigations (e.g. lying and standing

blood pressures, ECG). Prolonged heart

rhythm monitoring can be very helpful.

A 24-hour tape or a seven-day monitor

may be sufficient depending on the

frequency of the events. There are now

implantable monitors, similar in size to

a USB stick, which can monitor and

document a patient’s ECG for up to

three years – even infrequent events

can now be diagnosed! There are many

other investigations which can be useful,

either cardiological or neurological – which

ones to choose often becomes clearer

after the initial assessment.

The new guidelines place special emphasis

on the cardiological causes of blackout

because of the association with sudden

death and emphasise the need for the

rapid assessment of patients to exclude

the more worrying causes. ‘Cardiac’ causes

can be divided into four main categories:

• Arrhythmias (brady- and

tachyarrhythmias)

• ‘Obstructive’ lesions e.g. aortic stenosis,

hypertrophic cardiomyopathy

• Orthostatic hypotension

• Vasovagal events/neurocardiogenic

syncope, or simple faints

The first two groups are of considerable

importance as they can be associated

with a significant increase in sudden death,

although extremely effective treatments

are available.

Pointers to the more worrying causes of

blackouts include:

• Occurring while lying flat

• Occurring while exercising

• Associated with palpitations

• In those with known structural heart

disease (e.g. previous myocardial

infarction) or with clinical signs of such

• With significant injury

• In those with a family history of sudden

death under the age of 40

• In those over the age of 65 without a

prodrome

The London Syncope Clinic aims to offer

patients a rapid (within 24-48 hours)

assessment of their blackout or dizzy spell.

An initial review with a cardiac physiologist

for an ECG and an echocardiogram

is followed by a consultation with a

Consultant Cardiologist with an expertise

in the management of syncope. Further

investigations, whether non-invasive or

invasive can then be undertaken and

onward referrals to other specialties can

be made within London Bridge Hospital,

thus allowing an integrated approach to

patient care and as close as is possible to

a one-stop clinic.

A Clinic for

Blackouts and

Dizzy Spells