Doctor Studies Mysterious Disorders

There’s an old shtick of a Jewish woman pretending to swoon “oy, I’m fainting” as a call for attention or protest.

Some people find no joke in their experience with autonomic disease resulting in a sudden drop of blood pressure, dizziness and loss of consciousness, a response that ultimately ends in complete recovery. Note that this is not analogous to a seizure, coma or shock.

Dr. Howard Snapper specializes in autonomic diseases from the cardiologic perspective. “Many functions, like digestion, blood pressure, temperature, heart rate, breathing, sleeping, bladder control and erectile dysfunction are part of the body’s autonomic system.

“When a patient presents to a cardiologist with chest pain, shortness of breath, palpitations, dizziness or fainting, it is the job of the cardiologist to rule out heart dysfunction as the underlying cause. Frequently, the evaluation is normal, and the patients are dismissed from the cardiologist without an answer.”

The first step, usually before patients get to Snapper, is a cardiology workup with stress test, echo cardiogram and heart monitor to rule out heart disease. “I want to be sure and not miss anything that could be dangerous,” he said.

Snapper, who was originally an interventional cardiologist, got formally involved in 2010 in this subspecialty. For years he studied journals and cutting-edge research to understand the relationship of autonomic presentations in cardiology.

He sees the full gamut of ages from 16 to 100 with physiologically complicated abnormalities of vasovagal syncope (fainting) not necessarily known to modern science.

“This traces back to the Bible and has different activating triggers like anxiety, pain or some stranger ones like smelling something noxious; perfume can cause fainting to some. Fortunately, it happens standing up and not while sitting or driving. Some can anticipate an episode by sudden light-headedness, nausea or heart pounding.”

He recommends different sets of therapies depending on the severity. There are some medications (off label like a beta blocker) that can be used as needed. Often staying hydrated can be the key. Some more serious cases have daily episodes.

This can also run in families.

Older patients may faint because their nervous system does not adjust blood pressure upon standing. Snapper also has to associate or rule out more serious underlying conditions such as Parkinson’s disease, diabetes, or previous radiation to the neck or face. Urologic, chronic constipation or erectile dysfunction in men can factor in. “Taking Viagra can cause a blood pressure drop and fainting episode. Taking Flomax [for enlarged prostate] can make it even worse.”

There is an emotional component that Snapper has to evaluate. “I look at psychiatric factors differently. Does this patient have chronic fear or worry out of proportion to a normal response? Concern over paying rent or coronavirus fear is not that. Some minds ‘worry, worry worry’ as a clinical diagnosis of anxiety.

“Think about delineating if a rapid heart rate, shortness of breath, tightness of the chest wall muscles, or light headedness manifests as mental or physical problems.

A second group might experience different symptoms like migraines or irritable bowel syndrome. Then there are those I refer to a psychiatrist. Ultimately the final pathway to the disorder is a high adrenaline rush.”

As a dizzy aside, there is a fascinating association with myotonic goats that faint when they become startled with a “fight or flight” response. These goats were first discovered in Tennessee in 1880 with a gene also found in mice and humans.

Known for being teachable and trainable, they faint for 10 to 15 seconds with an adrenalin rush. Male bucks, for example, might faint preparing for sex. Snapper concurs that may be a similar autonomic response to what he sees in humans.

Here’s Snapper’s advice to maintain good heart health: Control your blood pressure, don’t smoke, manage cholesterol, and test/treat diabetes. Based at Wellstar Kennestone Hospital, Snapper has two children at The Epstein School, enjoys piloting private planes and playing piano. He hails from Boston and trained at University of Massachusetts, Tufts, and Northwestern universities.

He established the first cardiac screening program for student athletes in Cobb County using echocardiography.