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What Causes Frequent Syncope Episodes While On Brilinta?
Posted on
Wed, 3 Feb 2016
Wed, 3 Feb 2016
Answered on
Thu, 14 Apr 2016
Last reviewed on
Brief Answer:
I would explain as follows:
Detailed Answer:
Hello!
Welcome and thank you for asking on HCM!
I understand your concern and would like to have some more information on his therapy.
You should know that Brilinta does not lead to repeated syncope episodes. From the other hand this drug can interact with other drugs, leading to an increased risk of bleeding, because it is an anti platelet agent.
What was he taking for blood pressure when started taking Brilinta?
What is his past medical history? Why did he start taking Brilinta?
What are his actual blood pressure values?
You should know that there are different causes of syncope. A cardiac arrhythmia can not be excluded.
Does he feel any palpitations?
I would recommend you to closely monitor his blood pressure and his heart rate and refer them to his doctor.
Besides a careful physical exam, further tests are needed to establish the cause of repeated syncope episodess:
- a resting ECG and cardiac ultrasound to examine his cardiac structure and function
- an ambulatory 24-48 hours ECG monitoring to rule in/out possible cardiac arrhythmia.
- a chest X ray study
You should discuss with your doctor on the above issues.
Hope you will find this answer helpful!
Best wishes,
Dr. Iliri
I would explain as follows:
Detailed Answer:
Hello!
Welcome and thank you for asking on HCM!
I understand your concern and would like to have some more information on his therapy.
You should know that Brilinta does not lead to repeated syncope episodes. From the other hand this drug can interact with other drugs, leading to an increased risk of bleeding, because it is an anti platelet agent.
What was he taking for blood pressure when started taking Brilinta?
What is his past medical history? Why did he start taking Brilinta?
What are his actual blood pressure values?
You should know that there are different causes of syncope. A cardiac arrhythmia can not be excluded.
Does he feel any palpitations?
I would recommend you to closely monitor his blood pressure and his heart rate and refer them to his doctor.
Besides a careful physical exam, further tests are needed to establish the cause of repeated syncope episodess:
- a resting ECG and cardiac ultrasound to examine his cardiac structure and function
- an ambulatory 24-48 hours ECG monitoring to rule in/out possible cardiac arrhythmia.
- a chest X ray study
You should discuss with your doctor on the above issues.
Hope you will find this answer helpful!
Best wishes,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Hypertension meds were Lisinopril 5 mg and Metoprolol XL 50mg.
MI on Dec. 9th with XXXXXXX lab on 10th. 3 stents to open 100% blockage of LAD.
Current Echo shows good, with ejection fraction up from 40 % to current 55 %.
Usually now his B/P is between 120/70 and 140/90. During syncope, and immediately after warm up in rehab it drops, and then comes back up with more exertion. He has not passed out during rehab where it can be 80/60, I assume it is less at home because immediately after I cannot get a radial pulse, but as he comes around I can. I have captured low B/Ps when he first stands up from seated and walks. He has also had Panhypopituitarism for many years, and takes meds to compensate. He has chronic pain from injuries and has pain meds as well.
We are scheduling a 48 hour monitor, but the three days on the monitor in Dec., and the 12 sessions in rehab so far have not shown any arrhythmia.
I am afraid he will be injured, especially as he went back to work today. I worry about drug interactions.
His recent labs show a high anion gap and low rbc.
I am listed above in the profile, but my husband is a 59 year old male who works as a heavy equipment mechanic. He does not smoke or drink. He is 6'1" and currently weighs 217 pounds, he has been heavier, and lighter as well in the last few years. He also suffers from depression.
He does not have palpitations. He gets pale, shaky and says things start to go grey. He gets little warning although we are beginning to see the pattern. He falls pretty hard if he cannot get ahold of something or sit back down. Sunday he bent in the side of my stove with his head on the way to the floor. I took a pulse as listed above, and a B/P as soon as I was sure he was coming to and I could get him settled more comfortably. So far only bruises and no broken bones.
MI on Dec. 9th with XXXXXXX lab on 10th. 3 stents to open 100% blockage of LAD.
Current Echo shows good, with ejection fraction up from 40 % to current 55 %.
Usually now his B/P is between 120/70 and 140/90. During syncope, and immediately after warm up in rehab it drops, and then comes back up with more exertion. He has not passed out during rehab where it can be 80/60, I assume it is less at home because immediately after I cannot get a radial pulse, but as he comes around I can. I have captured low B/Ps when he first stands up from seated and walks. He has also had Panhypopituitarism for many years, and takes meds to compensate. He has chronic pain from injuries and has pain meds as well.
We are scheduling a 48 hour monitor, but the three days on the monitor in Dec., and the 12 sessions in rehab so far have not shown any arrhythmia.
I am afraid he will be injured, especially as he went back to work today. I worry about drug interactions.
His recent labs show a high anion gap and low rbc.
I am listed above in the profile, but my husband is a 59 year old male who works as a heavy equipment mechanic. He does not smoke or drink. He is 6'1" and currently weighs 217 pounds, he has been heavier, and lighter as well in the last few years. He also suffers from depression.
He does not have palpitations. He gets pale, shaky and says things start to go grey. He gets little warning although we are beginning to see the pattern. He falls pretty hard if he cannot get ahold of something or sit back down. Sunday he bent in the side of my stove with his head on the way to the floor. I took a pulse as listed above, and a B/P as soon as I was sure he was coming to and I could get him settled more comfortably. So far only bruises and no broken bones.
Brief Answer:
I would recommend as follows:
Detailed Answer:
Hello again!
Thank you for the additional information!
These episodes seem to be related to low blood pressure. As you refer, you don't catch the radial pulse in those moments. This means that there is a decrease in his blood pressure, which could be related to a cardiac arrhythmia or orthostatic hypotension.
A three days Holter monitoring sometimes is not able to detect a possible cardiac arrhythmia.
A prolonged one month ECG monitoring may be needed in up to 10 % of the cases.
From the other hand his past medical history of panhypopituitarism is really concerning for possible low cortisol plasma levels.
I would recommend checking his cortisol levels, fasting glucose and blood electrolytes.
A Head up Tilt test may be needed to exclude possible orthostatic hypotension.
If all these tests result normal, a brain EEG could be needed to rule in/out possible epilepsy seizures, which could be related to his symptomatology.
Hope to have been helpful!
Kind regards,
Dr. Iliri
I would recommend as follows:
Detailed Answer:
Hello again!
Thank you for the additional information!
These episodes seem to be related to low blood pressure. As you refer, you don't catch the radial pulse in those moments. This means that there is a decrease in his blood pressure, which could be related to a cardiac arrhythmia or orthostatic hypotension.
A three days Holter monitoring sometimes is not able to detect a possible cardiac arrhythmia.
A prolonged one month ECG monitoring may be needed in up to 10 % of the cases.
From the other hand his past medical history of panhypopituitarism is really concerning for possible low cortisol plasma levels.
I would recommend checking his cortisol levels, fasting glucose and blood electrolytes.
A Head up Tilt test may be needed to exclude possible orthostatic hypotension.
If all these tests result normal, a brain EEG could be needed to rule in/out possible epilepsy seizures, which could be related to his symptomatology.
Hope to have been helpful!
Kind regards,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you for your suggestions. We are looking at some of the options you mention. Further we are looking more closely at possible drug interactions. I may have more question as we go.
XXXXXXX Scott
XXXXXXX Scott
Brief Answer:
You are welcome!
Detailed Answer:
You are welcome,
Feel free to ask me directly again, in case of any further uncertainties.
Greetings!
Dr. Iliri
You are welcome!
Detailed Answer:
You are welcome,
Feel free to ask me directly again, in case of any further uncertainties.
Greetings!
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you. We will follow up on your suggestions and let you know what if anything we find. They are already making some med changes. Labs taken during the MI treatment indicated a low cortisol level. They increased his hydrocortisone (IV) and added IV insulin to counter its BG effects. Back at home they added glipizide to his metformin, and he went back to taking 30 mg hydrocortisone am and 20 pm as he had for many years. No idea where the cortisol level is right now but I understand that the hydrocortisone dose he is on is the XXXXXXX so no idea where to go from there if it is still low. The explanation we got was the cortisone levels went down because of the rise in troponin and general stress the heart was under. XXXXXXX
Brief Answer:
A comprehesive differential diagnosis is necessary.
Detailed Answer:
Dear XXXXXXX
As I explained you above, I recommend considering a comprehensive investigation of your husband repeated syncope and falling.
First starting with actual blood cortisol levels, and also a possible implication of associated orthostatic intolerance.
In such case, Tilt test is helpful.
Also and interaction between Lisinopril and Glipizide may increase the risk for hypoglycemia which may also be responsible for those episodes of fainting.
In such case, as episodic hypotension is confirmed, I would recommend to discuss with his prescribing doctor on a possible Lisinopril dose reduction or withdrawal.
In case blood cortisol level result low, then a review of daily Hydrocortisone dose should be considered (a possible dose increase).
Wishing that the above recommendations will be helpful to you,
Regards,
Dr. Iliri
A comprehesive differential diagnosis is necessary.
Detailed Answer:
Dear XXXXXXX
As I explained you above, I recommend considering a comprehensive investigation of your husband repeated syncope and falling.
First starting with actual blood cortisol levels, and also a possible implication of associated orthostatic intolerance.
In such case, Tilt test is helpful.
Also and interaction between Lisinopril and Glipizide may increase the risk for hypoglycemia which may also be responsible for those episodes of fainting.
In such case, as episodic hypotension is confirmed, I would recommend to discuss with his prescribing doctor on a possible Lisinopril dose reduction or withdrawal.
In case blood cortisol level result low, then a review of daily Hydrocortisone dose should be considered (a possible dose increase).
Wishing that the above recommendations will be helpful to you,
Regards,
Dr. Iliri
Note: For further queries related to coronary artery disease and prevention, click here.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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