What is the appropriate management for a 31-year-old male experiencing recurrent syncope (fainting) episodes, with the first episode occurring in 2021 and the second episode last month, and a normal electrocardiogram (EKG) result, with no history of seizures (sz)?

From the Guidelines

I strongly recommend a comprehensive evaluation for this 31-year-old male with recurrent syncope and "lhaphing" (likely meaning shaking), prioritizing cardiac and neurological causes. The patient's symptoms, as described, could represent vasovagal syncope, cardiac arrhythmias, or atypical seizures, and it is crucial to determine the underlying cause to guide treatment and prevent potential complications 1.

Initial Assessment and Referral

Given the recurrent nature of the syncope and the presence of shaking, which could be indicative of seizure activity or myoclonic jerks, a thorough cardiac and neurological evaluation is warranted. Referral to a cardiologist for a thorough cardiac workup, including a 24-hour Holter monitor, echocardiogram, and possibly a tilt-table test, is essential to rule out cardiac causes of syncope. Additionally, a neurology consultation with an EEG should be arranged to evaluate for possible seizure activity, despite the patient's lack of prior seizure history 1.

Patient Advice and Monitoring

While awaiting these evaluations, it is advisable for the patient to avoid driving and operating dangerous machinery, stay well-hydrated, and rise slowly from sitting or lying positions to prevent injuries from potential future episodes. Keeping a detailed diary of any episodes, including preceding symptoms, duration, and recovery, will also be helpful in identifying patterns or triggers 1.

Importance of Prompt Evaluation

The normal in-clinic EKG, although reassuring, is insufficient to rule out intermittent cardiac arrhythmias. Prompt evaluation is crucial as recurrent unexplained syncope can indicate serious underlying conditions requiring specific treatment. The guidelines emphasize the importance of identifying the cause of syncope to initiate appropriate management and prevent adverse outcomes 1.

Conclusion of Recommendations

In summary, a comprehensive evaluation including cardiac and neurological assessments is necessary for this patient. The goal is to identify the underlying cause of the syncope and shaking, which will guide specific treatment and management strategies to improve the patient's quality of life and prevent potential complications.

From the Research

Possible Causes of Syncope

• The patient's symptoms of passing out with laughing really hard could be related to laughter-induced syncope, a rare condition where syncope is triggered by laughter 2, 3.
• Laughter-induced syncope is usually a single event, but may present as recurrent attacks, and is often a subtype of benign Valsalva-related syncope, with autonomic reflex arcs coming into play that ultimately result in global cerebral hypoperfusion 3.
• Other possible causes of syncope, such as cardiogenic causes, epilepsy, or cataplexy, should be ruled out, especially since the patient has no history of seizures and a normal EKG 2, 4, 5.

Diagnostic Approach

• A thorough history taking and physical examination are essential in diagnosing the cause of syncope, and may help differentiate between laughter-induced syncope and other conditions such as cataplexy or epilepsy 2, 5.
• Additional tests, such as electroencephalography and magnetic resonance imaging, may be necessary to rule out underlying neurological conditions, but were unremarkable in a case of laughter-induced syncope 2.
• Home video recordings may also be helpful in diagnosing cataplexy and differentiating it from other conditions, such as syncope or pseudocataplexy 5.

Management

• If the patient is diagnosed with laughter-induced syncope, reassurance and explanation of the condition may be sufficient, as the prognosis is good in the case of neurally mediated attacks 2.
• If the patient is diagnosed with cataplexy, symptomatic treatment with antidepressants, such as fluoxetine, or sodium oxybate may be effective in reducing the frequency of cataplectic episodes 4, 6.
• Management of narcolepsy, if present, may also involve non-pharmacological approaches, such as sleep hygiene advice and safety measures, as well as pharmacological treatment with medications such as Modafinil, Armodafinil, or Pitolisant 6.