Recurrent Syncope in a Patient With a Varying Ejection Fraction
You are asked to see a 44-year-old African-American female after a recent episode of frank syncope. On interview she relates a history of palpitations, near syncope, and three episodes of frank syncope over the past two years. An echocardiogram, performed about two weeks after her first syncopal event, revealed trace MR, a LVEF of 50-55% and PA systolic pressures of 25-30mmHg. A myocardial perfusion study showed no inducible ischemia and an EF of > 60%. An ECG was purportedly normal; no cardiac monitoring was performed at that time.
She was diagnosed with systemic lupus erythematosus (SLE) in her mid-20s. She has had several flares involving the thyroid, skeletal muscles and kidneys. Although your review of her records does not find a specific diagnosis of myocarditis, her cardiac function can be compromised during these more acute phases of her illness. She was hospitalized two months prior to today's visit with a SLE flare associated with NYHA class III CHF symptoms including orthopnea and dyspnea provoked by ambulation. Prior to admission she had noted palpitations, tachycardia and near syncope, but no frank syncope. Telemetry monitoring during this hospitalization detected nonsustained ventricular tachycardia of up to 15 beats, but no sustained atrial or ventricular arrhythmias. AV conduction was normal, with a PR interval of 155ms. An echocardiogram while hospitalized showed an EF of 20-25% in a globally hypokinetic pattern, but with no overt valvular abnormalities. CHF medical therapy including carvedilol, telmisartan, spironolactone, furosemide and digoxin was begun. Her SLE flare was treated with IVIG and intravenous steroids as an inpatient and with hydroxychloroquine and oral steroids at discharge.
Two weeks post discharge she underwent a cardiac magnetic resonance imaging (CMR) with gadolinium: normal diastolic and systolic function with an LVEF of 54% were seen. Some mild intensity delayed gadolinium enhancement was noted at the LV apex.
Her CHF symptoms have improved to NYHA class II - she easily tolerates ambulation but more strenuous exertion causes dyspnea. She is compliant with all CHF medical therapy initiated while hospitalized. Despite this she suffered yet another syncopal event a few days prior to your assessment. She describes her event as a brief sensation of palpitations followed by an abrupt loss of consciousness. She denies nausea, diaphoresis or a gradual development of malaise. She is able tolerate standing for prolonged periods without provocation of near syncope. An echocardiogram in your office shows mild systolic dysfunction with LVEF of 45-50% but is otherwise unremarkable. ECG shows sinus rhythm at 68bpm with PR 162ms, QRS 76ms and QTc 402ms. No overt conduction, ST or T segment abnormalities are present.
During your discussion with the patient, you recommend: