Vaso Vaga / heart rhythm/ low bp

[Robfromwales]

I have a TAA , BAV and mild aortic regurgitation. I had afib once last year for 12 days with heart rate about 75 when normally say 55. It corrected itself in 12 days. I am on 32 mg canderstartin and 2.5 indapimide. Yesterday at 9am after eating and drinking , sat at computer working at home. Sadly felt unwell. Heady, clammy, sick, vision not right. Thankfully wife comes in and say 2/3 mins later I feint whole sat down. Felt terrible before and after. Straight to a and e who were great. BP about 98-63 and heart rate 48 when I get seen ( which was quickly). Tests throughout day all normal ( ecg , x ray bloods etc) . They are thinking vaso vaga , heart rhythm , BP although I think low bp can be part of vaso vaga. I had mris and cats last sept/ oct as part of TAA finding so these weren’t repeated as they didn’t think it was dissection or anything like that.

Anyone had anything like this and what was diagnosed?

Also Been reading about vagal nerve and I interestingly I have been having undiagnosed jaw pain off and on which Isnt dental, or blood supply/cardiac. Any chance that TAA which is in ascending aorta ( 4.88) with dilated root could be pressing on or interfering with nerve?

Thoughts or advice?

BTW- next echo re TAA and BAV in aug

[Cliff_G]

Hi Rob,

There are a few things going on here. Yes, it does sound like a touch of vasovagal syncope, otherwise known as the common fainting, but that normally happens immediately you stand up, from your description this happened when you were sitting down. Yes, it's probably due to a touch of low blood pressure. It is also true that the body can react to food by increasing vagal tone, which slows your heart rate down, so I'd say both low BP and perhaps a vagal reaction to eating. However, as you have a TAA, in my view they really should have CT'd your whole aorta anyway. Some ADs happen with little pain, or with transient pain that goes away.

The candesartan and indapamide are both treatments for high blood pressure. These are doing the business, by the sound of things, and I presume you were put on them to keep your BP under control because of your TAA.

TAAs are pretty much universally asymptomatic, so the TAA affecting the nerves is unlikely.

Putting aside the fainting for a moment, your biggest risk by far is that your TAA dissects, and you are at a slightly higher risk because of your BAV - these two are known to be associated. It's therefore good that you are being monitored by CT / MRI. Also candesartan is an ARB that confers some slowing down of the growth rate of the aorta (definitely in Marfans and similar, possibly for those without those syndromes), the other one is beta blockers.

Your 4.9 cm ascending aorta is within the bounds of the current guidelines and standard of care, in that for many years, no surgery is undertaken before you get to 5.5 cm, the thinking being is that at that point the risk of dissection becomes higher than the risk of surgery. But there are a couple of things here. 1. Surgery is much safer now than when those rules were set down, and 2. the value of 5.5 cm needs to be adjusted downward in certain circumstances, to 5 or 4.5, mainly in the presence of known genetic mutations associated with dissections. But this is a statistical thing, diameter is not an exact science. Some people have reached 8 cm or more and not dissected, plenty of people dissect before 5.5 cm (yours truly).

If you are not already, I would encourage you to get yourself under the care of a specialist aortic centre, where they understand all of the factors affecting this, and where you will get the best care to prevent a dissection.

I would also encourage you to wear a medical alert bracelet or neck tag advising of your aortic risk. This will help your doctors to know what to look for if you ever have a dissection - ADs are often wrongly diagnosed as heart attacks - a fair number of overlapping symptoms.

You already know of the dissection risk, and I don't want to cause excessive concern over this, but I do wish someone had told me these things before I dissected in 2017.

Best wishes.

If you want further reading, my story is at aortichope.org/post/survivo... Not my voice on the video!

[Robfromwales]

Thanks Cliff for the most helpful reply. Yes I was advised it wasn’t classic vaso vaga as sitting down. As a result , not driving for a month. I have feinted before in more classical circumstances eg blood but this felt much worse. But a least I had say 3-5 mins of pre warning. I am also now more regularly checking BP and pulse. I want to keep it below 110-80 for the TAA. I am currently experimenting with one day on one day off diuretic to see if I can stay around there.I had been thinking about a medic band but given the collapse will do something about it. I guess as a general member of public is unlikely to know what a TAA is or BAV is - what would you suggest ( I think number of characters is limited on these).

Yes - I am aware that biggest risk is dissection or rupture . I still play cricket but don’t lift anything heavy and didn’t do weights . As others have noted USA seem to intervene earlier at 5cm but I don’t know if that is risk based or insurance driven. One other commentator on here thought European standards (as you say currently generally at 5.5 cm unless other circumstances dictate) may be reassessed to see if they should be lowered.Morriston Swansea in South Wales or Heath Cardiff as nearest main surgical cardio bases. I have great care through local hospital .

I am being monitored by echo not mri or Ct. I am aware that this isn’t gold standard but is I assume good enough to know if anything significant is happening. I also note from TAA forum on FB that TAA can be stable or grow (sometimes quickly). As you know I am in optimal medication so that’s all the medical intervention necessary at the moment.