The Patient Was…

The patient was a 79-year-old woman who had experienced eleven falls in the previous 18 months.

She was a distant relative of one of my patients who had tried to get her to see me after one of her earlier tumbles. But she was fiercely proud of her independence and considered any such action to be an admission of weakness and vulnerability. She even resented the description of her problems as “suffering” a series of falls; she didn’t suffer, she insisted, and the falls were nothing but a nuisance.

When she finally consented to see me, it was only to stop the nagging of her relative. It was clear from the start that she was unhappy to be sitting across from me in my consultation room.

Her description of each of the incidents was identical. She would be in her usual state of health and awareness; suddenly, without any warning, she would fall without even being aware of it. After a brief period of apparent loss of consciousness, she would awaken, find herself on the ground, pick herself up, and go about her usual business. There were no warning symptoms before the episodes, and no signs of a seizure such as loss of bladder or bowel control or biting of her tongue. Amazingly, on not a single occasion did she sustain any injury whatsoever.

Careful questioning failed to disclose any other symptoms that might have given a clue to the cause of her episodes. She did not have vertigo or lightheadedness or faintness before the fall, and there were no symptoms right afterward that might hint at some underlying problem. They were like so-called “drop attacks,” but unlike classic drop attacks they were accompanied by loss of consciousness.

There were no features in her medical history that gave a clue to what might be the underlying cause of her symptoms. Except for her somewhat advanced age, which made almost any medical explanation more likely, she seemed to be in very good health. A thorough physical examination, with particular attention to cardiovascular and neurologic systems, was also unrevealing of any pathology.

My suspicion after hearing her story and examining her was that she was having very intermittent episodes of what is called Complete Heart Block. This refers to an interruption of the heart rhythm in which electric signals that normally trigger contraction of the heart muscles are blocked from reaching those pumping muscles.

The heart depends on electric signals for most of its work. In fact, cardiologists sometimes refer to the heart in jest as an “electric organ.” Specific cells in a small area located in the right upper portion of the heart normally generate electric signals. These electric currents travel over specialized pathways to an area lying between the upper and lower heart chambers, the atria and ventricles, respectively. After a brief delay, the signals are then transmitted down to the pumping muscles of the ventricles and trigger the muscle contractions that send blood around the body.

An interruption in the generation or transmission of electric signals can occur at any place along the electric circuit. Failure to generate signals and lack of transmission of the signals can each explain instances of sudden interruption of the heart rhythm, with resulting loss of consciousness since blood doesn’t get pumped to the brain. Complete Heart Block refers to the failure of signals from the upper heart chambers to get through the specialized area, called the atrio-ventricular node (AV node), that lies between the upper and lower heart chambers.

When I recorded the patient’s electrocardiogram (ECG), a graphic representation of the electrical activity of the heart, there was a helpful clue that pointed to a possible interruption of the heart rhythm, as I suspected. There was, on the ECG, a slight delay in the passage of the electric signals through the AV node between the upper and lower heart chambers. Although the delay was only a fraction of a second, any delay may be significant in terms of a potential cause for the patient’s symptoms.

A delay in signal transmission through the AV node, without full blockage of the signal, is called First Degree Heart Block. Although this is not associated with any symptoms, it suggests that from time to time there might be longer delays, and even occasional instances of Complete Heart Block.

I told the patient what I suspected she had, but I could not prove it. By monitoring her heart rhythm over a longer period of time, we might be lucky enough to document a rhythm abnormality that would explain her falls. She agreed, and we hooked her up to a portable long-term monitoring device that would record her heart rhythm over a twenty-hour period. She had no symptoms during the monitoring period, which was not surprising since the attacks were quite infrequent. And the heart rhythm monitor showed no abnormalities.

I explained to the patient that if she was indeed having periods of Complete Heart Block, the only advisable treatment was the insertion of an artificial pacemaker that would provide the necessary electric signals to the heart muscle when her own electrical circuitry was blocked.

She categorically refused. If I couldn’t prove what she had, she was not going to have a pacemaker inserted into her. I explained that the very intermittent nature of her symptoms meant it was unlikely that we would be monitoring her just at the right moment. But she was adamant: If I couldn’t prove the diagnosis, she wasn’t going to undergo the procedure just on my suspicion, however well informed it might be. She reminded me that her falls were not serious, since she had never hurt herself in one of the episodes. She refused to accept that the lack of injury was just an extraordinary example of good luck.

About two weeks later, she called me in a panic. “I’m coming in for a pacemaker,” she announced. “I want it now!”

“What happened? I asked. “What changed your mind?”

“I was crossing the street,” she explained, “and I woke up lying on the double yellow line dividing the traffic going by in both directions. I could have been killed.”

“You know that while I think the pacemaker will cure the problem, I can’t promise it,” I reminded her.

“I know,” she said, “but I just have to hope you’re right.”

She was admitted to the hospital the next day, and a permanent pacemaker was inserted by one my cardiac surgical colleagues. We never proved the diagnosis  —  but she never had another attack.

In medicine, as in many other situations in life, decisions may have to be based on incomplete information, experience, and intuition. Sometimes, you can opt to do nothing and get away with it. But other times, you may be forced to act, and to do so without proof or substantial evidence that you’re doing the correct thing.

If you are lucky, time will prove you did right.