Guest: Dr. J. Philip Saul - Pediatric Cardiology
Host: Dr. Linda Austin – Psychiatrist
Announcer: Welcome to an MUSC Health Podcast.
Dr. Linda Austin: I am Dr. Linda Austin. I am talking today with Dr. Philip Saul, who is the Director of the Pediatric Cardiology Program here at the Medical University of South Carolina. Dr. Saul a symptom that children sometimes have, the parents may not be aware of or may not think of as a heart symptom is fainting; pretty common, just how common is it for a child to faint?
Dr. J. Philip Saul: Well, it turns out that it’s probably the most common cardiac symptom in childhood. If you ask a classroom of medical student who are mostly between 18 and 25, how many of them have ever fainted, about a third of them will raise their hand and there is actually a study that shows the same thing and another one is here, so it’s an extremely common symptom. Now most of the time, we don’t think of it is much of a problem, but occasionally it can be.
Dr. Linda Austin: What are the circumstances that would lead you to say to parents, you would really order, look at this further?
Dr. J. Philip Saul: Often what happens is fainting can run in family, so child faints once, parent doesn’t worry about it that much, but when they faint the second time they usually called their pediatrician, and the pediatricians know that fainting can be a sign that there is a risk of a more serious problem that might cause sudden death, and so the pediatricians are immediately keyed into thinking about what are the issues that should lead me to refer this patient to a cardiologist or just handle it right here.
Dr. Linda Austin: Then, in terms of advice to parents, would you recommend the parents that it’s okay to wait until that second episode before they call the pediatrician?
Dr. J. Philip Saul: I think a lot of it depends on how serious it is? If a child faints because they have caught their in the door or because they have seen some blood, some of the common things that we associate with fainting then it’s probably okay to wait for another event. If a young child faints under the age of 5 to 7 or if the circumstances don’t really fit what you think about is causing fainting then it probably makes sense to go to the pediatrician or even to the emergency room for it. I think the thing that concerns us the most both as physicians, parents, and the lay people in the community is when a child faints in association with an athletic event then not all of those are problem, but those are ones where we are going to be much more aware that an evaluation needs to be done to make sure that it’s not a severe event.
Dr. Linda Austin: I would think especially in a climate like Charleston where it gets very, very hot; kids get dehydrated, there are out in the sun for a longtime, the fainting wouldn’t be that uncommon from dehydration, is this different kind of fainting that causes you concern?
Dr. J. Philip Saul: Yes, fainting when you are dehydrated or along with a viral illness is usually one of the common forms of fainting, but it doesn’t always occur with one of those events and so we have to aware that even those events, but almost any fainting spell could be due heart rhythm problem rather than a low blood pressure problem, which is what the typical form of fainting is. What I recommend as a pediatric cardiologist who specializes in this is that anybody who comes to a tension for fainting should have at least an electrocardiogram done and it turns out that we can rule out a wide variety of the more severe problems that can cause fainting, so that we can tell whether this is somebody who is at risk for the rare of sudden death in a young person versus just a benign event that we can give some good advise for.
Dr. Linda Austin: And of course an electrocardiogram is a very simple procedure. It only takes a few minutes.
Dr. J. Philip Saul: That’s absolutely right. It’s a very inexpensive procedure. I think many of these patients have much more complicated and expensive test like electroencephalograms EEGs or MRIs of the brain before they get to the EKG and yet the EKG is really the most important test in those circumstances. Some patients need little more extensive testing and may be they need an echocardiogram to rule out abnormal thickening of the heart muscle or an exercise test to see what the response to exercises, but the vast majority can have a good history to figure out what are the circumstances of the fainting event and an EKG to rule out some of the more significant rhythm abnormalities.
Dr. Linda Austin: When you look at an EKG, can you begin to tell what kind of arrhythmia there is? I am sure there are not all alarming.
Dr. J. Philip Saul: Sure, a lot of time we don’t actually see the arrhythmia on EKG, the abnormal heart rhythm, but we see 4:34 tell-tale signs, so we may see a little upsloping of one of the waves of the EKG that tells us there is something called Wolff-Parkinson-White syndrome. We may see a prolongation of the recovery period of the heart on the EKG, which might be a cause of long QT syndrome or other minor little details that really a pediatric cardiologist would be the best to pickup one that would tell us if the patient has a risk factor.
Dr. Linda Austin: What about medications as a cause of arrhythmia?
Dr. J. Philip Saul: Well, that is a great question because it has been in the news a lot lately for two different reasons, one is for the attention deficit disorder drugs, the stimulants that there has been a lot of question of whether those drugs alone can cause fainting that’s severe that does cause sudden death, and I think parents can feel fairly reassured here that the number of such cases where it’s even possible is extremely low and if we look at the general population of people who aren’t on those drugs, the rate of sudden death is actually higher than that in the patients on the drugs, so my guess is that those drugs have very little, if any, impact on sudden death. Now, those drugs do cause the blood pressure to be a little higher, they can cause the heart rate to be a little higher, and those are things that need to be monitored, but not necessarily worried about sudden death. What we say is that if there are concerns with pediatrician or the psychiatrist, they should get an EKG and refer the patient for an evaluation and we will determine whether there is a real risk or not.
Dr. Linda Austin: Now this may be an overly broad question, but if there is an arrhythmia that warrants attention that puts the patient at risk for sudden death, what are some of the sorts of interventions that you would then pursue?
Dr. J. Philip Saul: Fortunately, if we can identify a patient upfront then we can almost always do something to prevent sudden death. Sometime we can do a curative procedure. We can do what’s called a catheter ablation or another procedure where we can actually take away the risk. Other times what we do is, put a patient on mediation, and then the more common treatment these days, if we knows somebody at risk, is to implant what is called an internal cardioverter-defibrillator (an ICD) and I think a lot of people know that from Vice President Cheney has one, but obviously he is a little older than most of our patients, but we can still put in such a device in a child and it’s like carrying a little ambulance crew around in your shoulder, so that the instant that the heart has a malignant or a severe abnormal rhythm, the device will respond, shock the patient, and bring the rhythm back to normal.
Dr. Linda Austin: So, it sounds as if the important news in all of this is that fainting spells should be taken seriously especially if the conditions are typical ones to produce it. They can be benign but not necessarily, but that there are very good treatment available.
Dr. J. Philip Saul: That’s correct, and fortunately we also have very good treatments for the benign kind. A lot of time, it’s just advice and there are some medications that can help too, so when we have patients who have frequent fainting but it’s not a heart rhythm problem, we can help them as well.
Dr. Linda Austin: Thank you so much Dr. Saul.
Dr. J. Philip Saul: Thank you.
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