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Syncope

What is it?
Syncope is the medical term for fainting. Syncope is a common problem. About one- third of people experience syncope at some point in their lives. And for the vast majority, syncope does not indicate a serious problem. In fact most people wake up on their own after fainting, and many of these people may not have another episode of syncope.

Occasionally people feel dizzy or lightheaded, but they don't actually pass out. Doctors call these episodes pre-syncope.

Syncope can happen for many reasons. Some are not cardiac (heart) related. For instance, syncope can be caused by pain or stress. But for many people who experience syncope, it is cardiac related. It is this type of syncope that is most dangerous. And it is this type of syncope that is described here.

Another name for the type of syncope described here: cardiac syncope.

What is the cause?
Syncope is caused by decreased blood flow to the brain.

There are two categories of heart problems that can cause syncope. In the first, a heart problem—like a damaged heart valve—obstructs blood flow. Syncope caused by an obstruction is relatively rare.

Arrhythmias are the second type of heart problem that can cause syncope. Arrhythmias, or irregular heart rhythms, can be either slow or fast.
• Slow arrhythmias called bradycardia sometimes cause syncope. If your heart beats too slowly, not enough blood reaches your brain.
• Fast arrhythmias known as ventricular tachycardia (VT) or ventricular fibrillation (VF) are the more likely cause of syncope. During VT or VF, the heart beats so fast that the lower heart chambers (ventricles) can't fill with enough blood before the blood is pumped out to the body. These arrhythmias can cause a dangerous type of syncope—or loss of consciousness—in which the heart is no longer pumping out enough blood.

Since VT or VF can cause sudden cardiac arrest (SCA) and sudden cardiac death (SCD), they are especially dangerous. To learn more about any of these conditions, go to the Health Conditions section.

What are the symptoms?
Cardiac syncope usually happens without warning. But sometimes people do notice symptoms beforehand:

• Palpitations (feeling that the heart is racing or that the heartbeat is irregular)
• Tightness in the chest
• Shortness of breath
• Sweaty palms
• Dizziness

What tests could I have?
Your doctor may suggest one or more of the tests listed below to check the electrical system in your heart. The test results can also help your doctor choose the best treatment(s) for you.

In some cases you may be sent to specialists for diagnosis and testing—and sometimes for treatment. To learn more, go to the Your Treatment Team section.

Echocardiogram
Electrocardiogram (ECG or EKG)
Electrophysiology (EP) Study
Event Recorder
Holter Monitoring
Tilt Table
Echocardiogram

What is an echocardiogram?
An echocardiogram (also called an echo) is a three-dimensional, moving image of your heart. An echo uses Doppler ultrasound technology. It is similar to the ultrasound test done on pregnant women. The echo machine emits sound waves at a frequency that people can't hear. The waves pass over the chest and through the heart. The waves reflect or "echo" off of the heart, showing:
The shape and size of your heart
How well the heart valves are working
How well the heart chambers are contracting
The ejection fraction (EF), or how much blood your heart pumps with each beat

What can I expect?
When you have an echocardiogram, you undress from the waist up, put on a hospital gown, and lie on an exam table. The technician spreads gel on your chest and side to help transmit the sound waves. The technician then moves a pen-like instrument (called a transducer) around on your chest or side. The transducer records the echoes of the sound waves. At the same time, a moving picture of your heart is shown on a special monitor. You may be asked to lie on your back or your side during different parts of the test. You may also be asked to hold your breath briefly so that the technician can get a good image of your heart. An echo is a painless test. You feel only light pressure on your skin as the transducer moves back and forth.

Electrocardiogram (ECG or EKG)

What is an ECG?
An electrocardiogram (ECG or EKG) reveals how your heart’s electrical system is working. The ECG senses and records your heartbeats, or heart rhythms. The results are printed on a strip of paper. An ECG can also help your doctor diagnose whether:
You have arrhythmias
Your heart medication is effective
Blocked coronary arteries (in the heart) are cutting off blood and oxygen to your heart muscle
Your blocked coronary arteries have caused a heart attack

In all, there are three kinds of tests that record your heart's electrical activity, each for a different period of time:
Electrocardiogram (ECG)—done in the doctor's office. It records your heart rhythms for a few minutes.
Holter monitoring—records and stores (in its memory) all of your heart rhythms for 24-48 hours.
Event recorder—constantly records your heart rhythms. But it stores the rhythms (in its memory) only when you push a button.

What are the parts of an ECG strip?
The peaks on an electrocardiogram (ECG) strip are called waves. Together, all the peaks and valleys give your doctor important information about how your heart is working:

• The P-wave shows your heart's upper chambers (atria) contracting
• The QRS complex shows your heart's lower chambers (ventricles) contracting
• The T-wave shows your heart's ventricles relaxing

What can I expect?
When you have an electrocardiogram (ECG) you undress from the waist up, put on a hospital gown, and lie on an exam table. As many as 12 small patches called electrodes are placed on your chest, neck, arms, and legs. The electrodes, which connect to wires on the ECG machine, sense the heart's electrical signals. The machine then traces your heart’s rhythm on a strip of graph paper.

Electrophysiology (EP) Study

What is an EP study?
An electrophysiology (EP) study is a test of your heart's electrical system. While an electrocardiogram (ECG) gives an overview of your heart's electrical system, the EP study gives a more in-depth view. The test helps find out details about abnormal heart rhythms, called arrhythmias. The EP study can reveal:

• If you have an arrhythmia
• The cause of the arrhythmia
• Where the arrhythmia begins in the heart
• If you are at risk for sudden cardiac arrest (SC)
• The best treatment for an arrhythmia

The EP study begins when one or more leads are inserted into a blood vessel, usually in the groin. The doctor gently "steers" the leads toward your heart. Once in place, the leads sense your heart's electrical activity. One special lead also delivers electrical signals to your heart to trigger an arrhythmia. That’s to help find out how easily your heart can produce arrhythmias on its own.

During the EP study, your doctor closely monitors your heartbeats. If an arrhythmia occurs, the doctor treats you with:
Medications given through the intravenous (IV) line in your arm or hand
Electrical signals delivered to the outside of your chest through patches

In some cases, ablation (a form of treatment) is done at the same time as your EP study. (To learn about ablation, go to the Procedures part of the Medications& Procedures section.) Or your doctor can suggest other types of treatment after the EP study.

What can I expect?
Your test will be performed in a "cath lab." You undress, put on a hospital gown or sheet, and lie on an exam table. An intravenous (IV) line put into your arm delivers fluids and medications during the test. The medication makes you groggy, but not unconscious. Patches called electrodes are put on your chest. The electrodes monitor your heart's electrical signals during the test. A blood pressure cuff on your arm also regularly takes your blood pressure.

The doctor makes a small incision (usually in the groin) for the catheter. The groin area will be numbed so you shouldn't feel pain, but you may feel some pressure as the catheter is inserted. If the doctor delivers electrical signals to your heart, you might feel your heart racing or pounding. You won't be fully asleep, so during the test your doctor or nurse might ask you questions. Afterwards you may be in the hospital overnight, but most people have a fairly rapid recovery.

Event Recorder

What is an event recorder?
An event recorder is a small device that tracks your heart's electrical activity. An event recorder monitors your heart's electrical activity for an extended period of time—usually from a week to a month or more. The recorder is always on, but it saves your heart rhythms into its memory only when you push a button. Many recorders save recordings of your heart rhythms for 30-60 seconds both before and after you push the button.

An event recorder can help your doctor find out if you have abnormal heart rhythms, or arrhythmias. Arrhythmias might happen rarely, yet it is still important for your doctor to know about them and to treat them.

In all, there are three kinds of tests that record your heart's electrical activity, each for a different period of time:
• Electrocardiogram (ECG)—done in the doctor's office. It records your heart rhythms for a few minutes.
• Holter monitoring—records and stores (in its memory) all of your heart rhythms for 24-48 hours.
• Event recorder—constantly records your heart rhythms. But it stores the rhythms (in its memory) only when you push a button.

When the heart rhythms from any of these three tests are printed out, they all look the same: the electrical signals look like peaks and valleys. A doctor may suggest an event recorder when you have symptoms only once a week or once a month.

What can I expect?
Two sticky patches called electrodes are placed on your chest. The electrodes connect to wires on the event recorder. The electrodes sense your heart rhythms, while the event recorder records and stores the rhythms. Your doctor or nurse will show you how to take the electrodes off for bathing and then put them back on. The event recording device itself is the size of a small portable tape recorder. It fits easily on a belt or in a pocket.

You press the button when you feel symptoms. This causes the device to store a small segment of the recordings. Make sure your family and friends know how to start the recorder too. In case you have symptoms, they can help you press the recorder. Any stored recordings can be sent to your doctor's office, clinic, or hospital. The staff there will let you know if you need to follow up with your doctor.

You should be able to do most or all of your daily activities at home and work while using the event recorder. You won't feel anything while the event recorder is tracking your heart rhythms. However, sometimes your skin can become irritated from the sticky patches.

Holter Monitoring

What is Holter monitoring?
Holter monitoring uses a small recording device called a Holter monitor. The monitor tracks and records your heart's electrical activity, usually for 24-48 hours.

Holter monitoring can help your doctor find out if you have abnormal heart rhythms, or arrhythmias. Arrhythmias might happen rarely, yet it is still important for your doctor to know about them and to treat them.

In all, there are three kinds of tests that record your heart's electrical activity, each for a different period of time:

• Electrocardiogram (ECG)—done in the doctor's office. It records your heart rhythms for a few minutes.
• Holter monitoring—records and stores (in its memory) all of your heart rhythms for 24-48 hours.
• Event recorder—constantly tracks your heart rhythms. But it stores the rhythms (in its memory) only when you push the button.

When the heart rhythms from any of these three tests are printed out, they all look the same: the electrical signals look like peaks and valleys. A doctor may suggest Holter monitoring when you have symptoms at least once every day or two.

Your doctor may ask you to write down any symptoms you have during the test. Symptoms might include faintness, dizziness, or fluttering in the chest. You should note the time and how long the symptoms last. Your doctor might also ask you to write down when you exercise, take medications, or get upset. This can help your doctor see if there is a connection between your heart rhythms and your symptoms or activities.

What can I expect?
As many as seven 4-7 sticky patches called electrodes are placed on your chest. The electrodes connect to wires on the Holter monitor. The electrodes sense your heart rhythms, while the monitor records and stores the rhythms. Since the electrodes cannot get wet, you should shower or bathe before you begin the Holter monitoring, and not at all during the testing. The Holter monitor device itself is the size of a small portable tape recorder. It fits easily on a belt or can be worn on a shoulder strap.

You should be able to do most or all of your daily activities at home and work while using the Holter monitor. You won't feel anything while the Holter monitor is tracking your heart rhythms. After 24-48 hours, you return the monitor. A technician examines the recordings, notes whether you had any arrhythmias, and prepares a report for your doctor.

Tilt Table Test

What is a tilt table test?
The tilt table test checks to see how a change in position—from lying to standing—affects heart rate and blood pressure. Your doctor uses the test to try and reproduce your symptoms of syncope (fainting). There are many causes for syncope. One possible cause is a sudden slowing of the heart, combined with a drop in blood pressure. This reduces the amount of blood flowing to the brain, and fainting can result.

During the test, the table is tilted up at a 60 to 80 degree angle to see if syncope occurs. The technician checks your blood pressure during the test to see if falling blood pressure causes syncope. The technician also does an electrocardiogram (ECG) during the test to see if an electrical problem is causing the syncope. Depending on how you respond to the test, your doctor can decide:
What kind of treatment can work for you
Whether you need other kinds of tests

What can I expect?
Before your tilt table test you may be asked to undress and put on a hospital gown or sheet. You lie on a special table and an intravenous (IV) line is put into your arm. The IV delivers fluids and medications during the procedure. The technician puts a blood pressure cuff around your arm and often checks your blood pressure during the test. Patches called electrodes are put on your chest. The electrodes connect to wires on an ECG. The electrodes and ECG monitor your heart's activity and the heart rate during the procedure.

The table can be quickly tilted from a flat to an upright position. For your safety, you are strapped to the table with safety belts. There is also a headrest and a footrest to keep you comfortable during the test. You are also closely monitored during the test.

The technician asks you to report any symptoms during the test. You might also be asked not to shift your weight or move your legs during parts of the test. The table then tilts up, usually at a 60 to 80 degree angle. The technician monitors your heart rate and blood pressure the entire time. In some cases your doctor presses on the carotid artery (in your neck), to see if that causes fainting. In some cases, medication given through the IV line speeds up your heart rate.

What are the treatment options?
If your syncope is not heart related, you may not receive any heart or blood vessel related treatment.

There are many different causes even for cardiac-related syncope. For that reason, there is no one standard set of treatments. But if test results show that dangerous arrhythmias like VT or VF are the cause of syncope, then you will receive treatment. Your treatment might include one or more of the following medications and procedures.

Medications
Antiarrhythmics

Procedures
Cardioversion & Defibrillation
Defibrillator Implant
Pacemaker Implant

MEDICATIONS

Tips for Taking Heart Medications
If you have a heart or blood vessel condition, you might want to know more about some of the medications you take. The information in this section describes some medications commonly prescribed for heart or blood vessel conditions. It also includes some tips to help you take your medications as ordered.

Make sure you tell your doctor—or any new doctor who prescribes medication for you—about all the medications and supplements you take. Your doctor can then help make sure you get the most benefit from your medications. Telling your doctor this information also helps avoid harmful interactions between medications.

You may also want to discuss these topics with your doctor or nurse each time you get a new medication:

• The reason you're taking the medication, its expected benefits, and its possible side effects
• How and when to take your medications
• If you take other medicines, vitamins, supplements, or other over-the-counter products

In some cases, your heart needs several months to adjust to new medications. So you may not notice any improvement right away. It also may take time for your doctor to determine the correct dosage.

Blood tests are sometimes necessary for people who take heart medications. The blood tests help your doctor determine the correct dosage—and therefore help avoid harmful side effects.

Never stop taking your medication or change the dosage on your own because you don't believe you need it anymore, don't think it's working properly, or feel fine without it.

Be sure to talk to your doctor or nurse if you have:

• Questions about how your medications work
• Unpleasant side effects
• Trouble remembering to take your pills
• Trouble paying for your medications
• Other factors that prevent you from taking your medications as needed
• Questions about taking any of your medications

And don't hesitate to ask your pharmacist if you have questions about how and when to take your medications.

Antiarrhythmics

Antiarrhythmics affect the electrical system in your heart. You can understand the purpose of antiarrhythmics by looking at the root words of the term. Anti = counter or against; arrhythmia = an abnormal heartbeat or heart rhythm.

Some generic (and Brand) names
All medications are approved by the Food and Drug Administration (FDA) for a specific patient group or condition. Only your doctor knows which medications are appropriate for you.

amiodarone (Cordarone, Pacerone)
disopyramide (Norpace)
dofetilide (Tikosyn)
flecainide (Tambocor)
procainamide (Procanbid)
propafenone (Rythmol)
quinidine (Quinaglute)

Sometimes other categories of medications—beta blockers and calcium channel blockers—are used to help prevent arrhythmias.

What they're used for
To prevent and treat arrhythmias (abnormally fast or slow heartbeats, or heart rhythms)
To restore normal heart rhythms
How they work
Antiarrhythmic drugs work in different ways to change the electrical activity in your heart. Different drugs are used because the source of the arrhythmia can come from different places in the heart.

Taking antiarrhythmics can:
Restore a normal heart rhythm
Prevent abnormally fast rhythms.

Cardioversion & Defibrillation

What is cardioversion & defibrillation?
Both cardioversion and defibrillation deliver an electrical shock to the heart. The shock can restore a normal heartbeat. Both types of treatment are used in people who have abnormal heartbeats or heart rhythms, called arrhythmias.

Cardioversion is a lower-energy shock delivered to your heart. Cardioversion can stop a very fast arrhythmia.

Defibrillation is a high-energy shock delivered to your heart. You need this treatment if you have a very fast and chaotic arrhythmia in your heart's lower chambers (ventricles). For instance, defibrillation is needed for arrhythmias like ventricular tachycardia (VT) or ventricular fibrillation (VF). Defibrillation is the only effective treatment for VF. If VF is not treated, it can quickly lead to sudden cardiac death (SCD).

The concept behind cardioversion and defibrillation is the same. Both types of treatment stop all electrical activity in the heart for a second. When the heart resumes beating, its electrical system often works correctly once again. If you want to learn more about your heart's electrical system, go to the Heart & Blood Vessel Basics section.

How is cardioversion or defibrillation done?
Internal cardioversion is delivered by an implanted device. If you have an implantable cardioverter defibrillator (ICD), it can sense a fast arrhythmia. The ICD then delivers a low-energy shock. The shock can stop the arrhythmias and restore a normal heartbeat.
External cardioversion is delivered by an external device. This is a scheduled treatment often used to treat fast arrhythmias in the heart's upper chambers (atria).

Internal defibrillation is delivered by an ICD device. When the device senses an arrhythmia like ventricular fibrillation (VF), the ICD delivers a lifesaving shock.
External defibrillation is delivered by an external defibrillator. You've probably seen external defibrillators on TV medical dramas. The machine is connected to two paddles that deliver a shock to the outside of the chest. Because brain damage starts to occur within 4-6 minutes after VF begins, defibrillation should be done as soon as possible. Because fast arrhythmias can be so dangerous, some public buildings and airplanes now have external defibrillators.

What can I expect?
Internal cardioversion or defibrillation from an implanted device can come as a surprise if you aren't having symptoms. You will feel cardioversion but it may not be painful. On the other hand, a high-energy shock from defibrillation can be painful. But an arrhythmia like VF will rarely stop on its own—it must be treated for the person to survive. So defibrillation is typically a lifesaving therapy.

External cardioversion is usually a scheduled treatment in your doctor's office. Your doctor may recommend it if your atrial arrhythmias do not respond to medications. You undress and put on a hospital gown or sheet. You lie on an exam table and an intravenous (IV) line is put into your arm. The IV delivers fluids and medications during the short procedure. The medication makes you groggy, but not unconscious. Your doctor puts patches called electrodes on your chest. The electrodes connect to wires on the device. The device delivers the shock. Most people say they have little or no pain afterwards.

External defibrillation is done in an emergency situation. Someone who receives this treatment is typically unconscious. After the shock is delivered, there may be some pain and skin irritation on the chest (from the paddles).

Defibrillator Implant (ICD Device Implant)

What is a defibrillator (ICD device)?
An implantable cardioverter defibrillator (ICD) is a small device that treats abnormal heart rhythms called arrhythmias. Specifically, an ICD treats fast arrhythmias in the heart's lower chambers (ventricles). Two such arrhythmias are ventricular tachycardia (VT) and ventricular fibrillation (VF).

Arrhythmias result from a problem in your heart's electrical system. Electrical signals follow a certain path through the heart. It is the movement of these signals that causes your heart to contract. To learn more about your heart's electrical system, go to the Heart & Blood Vessel Basics section.

During VT or VF, however, far too many signals are present in the ventricles. In addition, the signals often do not travel down the proper pathways. The heart tries to beat in response to the signals, but it cannot pump enough blood out to your body. If you have either VT or VF, you are at high risk of sudden cardiac arrest (SCA). If not treated immediately with defibrillation, SCA can result in sudden cardiac death (SCD).

An ICD can treat VT and VF and restore your heart to a normal rhythm. So it reduces your risk of SCD. The device can deliver several types of treatment:

• Anti-tachycardia pacing (ATP) delivers very small amounts of energy to your heart—so small that you can't feel the treatment.
• Cardioversion is a low-energy shock that treats fast but regular arrhythmias.
• Defibrillation is a high-energy shock that treats fast and chaotic (irregular) rhythms. Defibrillation is painful for an instant, but it can also save your life.

A device implant is a procedure that uses local numbing. General anesthesia is usually not needed.

How is the implant procedure done?
An Implantable cardioverter defibrillator (ICD) system has two parts.
Device—the device is quite small and easily fits in the palm of your hand. It contains small computerized parts that run on a battery.
Leads—the leads are thin, insulated wires that connect the device to your heart. The leads carry electrical signals back and forth between your heart and your device.

Your doctor inserts the leads through a small incision, usually near your collarbone. Your doctor gently steers the leads through your blood vessels and into your heart. Your doctor can see where the leads are going by watching a video screen with real-time, moving x-rays called fluoroscopy.

The doctor connects the leads to the device and tests to make sure both work together to deliver treatment. Your doctor then places the device just under your skin near your collarbone and stitches the incision closed.

What can I expect?
Usually you are told not to eat or drink anything for a number of hours before the procedure. You undress and put on a hospital gown or sheet. Your procedure will be performed in a ”cath lab." You lie on an exam table and an intravenous (IV) line is put into your arm. The IV delivers fluids and medications during the procedure. The medication makes you groggy, but not unconscious.

The doctor makes a small incision near your collarbone to insert the leads. The area will be numbed so you shouldn't feel pain, but you may feel some pressure as the leads are inserted. You may be sedated when the device is tested, since it delivers a shock to your heart.

You may be in the hospital overnight, and there may be tenderness at the incision site. Afterwards most people have a fairly quick recovery.

Pacemaker Implant

What is a pacemaker?
A pacemaker is a small implanted device that treats abnormal heart rhythms called arrhythmias. Specifically, a pacemaker treats slow arrhythmias called bradycardia. A pacemaker can usually eliminate symptoms like shortness of breath, fatigue, and dizziness caused by bradycardia.

Arrhythmias result from a problem in your heart's electrical system. Electrical signals follow a certain path throughout the heart. It is the movement of these signals that causes your heart to contract. During bradycardia, however, too few signals flow through the heart. To learn more about your heart's electrical system, go to the Heart & Blood Vessel Basics section.

A pacemaker restores your heart to a normal rhythm. The pacemaker can also adjust to your body's needs. This is because the device has sensors that can detect:

• When you rest and need a slow heart rate
• When you exercise and need a faster heart rate

Sometimes a pacemaker is used as backup treatment only if your heart needs it. In other cases, a person's heart can no longer create its own electrical signals, or send them down the proper pathways. In these cases the heart depends on the pacemaker.

A device implant is a procedure that uses local numbing. General anesthesia usually is not needed.

How is the implant procedure done?
A pacemaker system has two parts.
Device—the device is quite small and easily fits in the palm of your hand. It contains small computerized parts that run on a battery.
Leads—the leads are thin, insulated wires that connect the device to your heart. The leads carry electrical signals back and forth between your heart and your device.

Your doctor inserts the leads through a small incision, usually near your collarbone. Your doctor gently steers the leads through your blood vessels and into your heart. Your doctor can see where the leads are going by watching a video screen with real-time, moving x-rays called fluoroscopy.

The doctor connects the leads to the device and then tests to make sure both work together deliver treatment. Your doctor then places the device just underneath your skin and stitches the incision closed.

What can I expect?
Usually you are told not to eat or drink anything for a number of hours before the procedure. You undress and put on a hospital gown or sheet. Your procedure will be performed in a ”cath lab." You lie on an exam table and an intravenous (IV) line is put into your arm. The IV delivers fluids and medications during the procedure. The medication makes you groggy, but not unconscious.

The doctor makes a small incision near your collarbone to insert the leads. The area will be numbed so you shouldn't feel pain, but you may feel some pressure as the leads are inserted. You may be in the hospital overnight, and there may be tenderness at the incision site. Most people have a fairly quick recovery.

Important Safety Information
Medications, procedures and tests can have some risks and possible side effects. Results may vary
from patient to patient. This information is not meant to replace advice from your doctor. Be sure to talk
to your doctor about these risks and possible side effects.

Cardiac resynchronization therapy pacemakers (CRT-P) and defibrillators (CRT-D) are used to treat
heart failure patients who have symptoms despite the best available drug therapy. These patients also
have an electrical condition in which the lower chambers of the heart contract in an uncoordinated way
and a mechanical condition in which the heart pumps less blood than normal. CRT-Ps and CRT-Ds are
not for everone including people with separate implantable cardioverter-defibrillators (CRT-P only) or
certain steroid allergies. Procedure risks include infection, tissue damage, and kidney failure. In some
cases, the device may be unable to respond to your heart rhythm (CRT-P only) or may be unable to
respond to iregular heartbeats or may deliver inappropriate shocks (CRT-D only). In rare cases severe
complications or device failure can occur. Electrical or magnetic fields can affect the device. Only your
doctor knows what is right for you.

GUIDANT is a trademark and HEARTISTRY is a service mark of Guidant Corporation. All other brand names mentioned are used for identification purposes only and are trademarks of their respective owners.

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www.guidant.com

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