Management of Syncope in a Patient with Borderline Personality Disorder and Concerning EKG Findings
The next best step in managing this 27-year-old male with syncope is to provide immediate fluid resuscitation while simultaneously arranging for urgent cardiac evaluation including echocardiography to assess for structural heart disease, particularly right ventricular hypertrophy. 1
Initial Assessment and Stabilization
Fluid resuscitation: This patient shows clear signs of dehydration (poor sleep, single meal daily, inadequate fluid intake) which is a common cause of syncope. Immediate oral or IV fluid bolus is indicated. 1
Medication review: The patient is on lamotrigine and escitalopram for borderline personality disorder. While these medications don't typically cause syncope directly, they may contribute to his poor sleep and potentially affect cardiac conduction.
Cardiac Evaluation
Concerning EKG Findings
The EKG findings of incomplete right bundle branch block (RBBB), right axis deviation, and possible right ventricular hypertrophy in a young patient are concerning and require further investigation:
Echocardiography: Urgent echocardiography is essential to evaluate:
Cardiac monitoring: Consider 24-48 hour continuous cardiac monitoring to detect any arrhythmias that may have caused the syncopal episode 1
Risk Stratification
The combination of syncope with bifascicular block (RBBB with right axis deviation) carries a higher risk of progression to complete heart block and is associated with excess mortality (risk ratio 1.47) 2
Further Diagnostic Workup
Complete laboratory evaluation: Review CBC and CMP results with particular attention to:
- Electrolyte abnormalities (especially potassium, magnesium)
- Renal function
- Hemoglobin/hematocrit (to rule out anemia)
Consider cardiac MRI: If echocardiography is inconclusive, cardiac MRI may be necessary to better evaluate right ventricular structure and function 1
Electrophysiology study: Should be considered if structural heart disease is identified or if initial workup doesn't reveal a clear cause of syncope 1, 2
Management of Psychiatric Conditions
Psychiatric consultation: While addressing the acute medical concerns, psychiatric consultation should be obtained to optimize management of borderline personality disorder
Medication review: Lamotrigine has shown mixed results in borderline personality disorder. While some small studies showed benefit 3, 4, larger randomized controlled trials found no significant clinical benefit over placebo 5, 6
Sleep hygiene education: Address the patient's poor sleep (3-4 hours) which may be contributing to his overall condition
Pitfalls and Caveats
Don't attribute syncope solely to psychiatric causes: Even in patients with psychiatric disorders, syncope requires thorough cardiac evaluation, especially with concerning EKG findings
Don't overlook dehydration: While cardiac causes must be investigated, the patient's poor fluid intake and nutrition are likely contributing factors that require immediate correction 1
Beware of incomplete evaluation: The combination of syncope with conduction abnormalities on EKG requires comprehensive cardiac assessment, not just fluid resuscitation
Monitor for progression: Patients with bundle branch blocks require follow-up to monitor for progression to higher-degree AV block 2
Follow-up Plan
- Short-term: Daily fluid intake goals (minimum 2L/day), improved nutrition (3 meals/day)
- Medium-term: Follow-up echocardiography and EKG in 3-6 months if initial evaluation shows abnormalities
- Long-term: Regular cardiac follow-up if structural abnormalities are identified
By addressing both the acute medical concerns and underlying psychiatric condition, this approach provides the best chance of reducing morbidity and mortality while improving the patient's quality of life.