Saturday, March 13, 2021

Another day, another doctor visit, another deductible... and a joke!

Since our last installment, I've had two doctor appointments: one with my primary care physician, and one with my cardiologist (who is part of the cardiology group that was involved in my treatment at the hospital last week). Neither visit was particularly revealing; in fact, both seemed more a waste of time and money (deductible) than informative and useful. That said, I probably would do both again if this happens again (at least in part because the cardiologist, while saying he didn't believe any additional tests were needed at this time, said that were it to happen again, he would order additional tests, likely to include a 30-day (or longer) heart monitor). I think perhaps my primary care physician was overbooked, as it seemed she had a lot of patients come in all at the same time as my appointment (she's usually pretty good, but it seemed quite rushed this visit).

Since those visits, however, I did a little research on my own, and I believe that what I experienced last Monday (that is, Monday of last week) is "post exercise syncope" or "post exertion syncope" - as can be described in this article (an interesting read, where a pacemaker was eventually implanted to prevent post-exertion syncope in the 29-year-old case study) or this article. I don't think what I experienced was "exertion syncope," as can be found in this article, which describes both post-exertional syncope and during-exercise syncope:

Post-exertional syncope frequently occurs when exercise is stopped suddenly and reduction of lower extremity muscle pumping results in less cardiac venous return and cardiac output. In such a circumstance, an acute increase in myocardial contractility can lead to activation of the cardiac depressor reflex inducing concomitant paradoxical bradycardia. As a result, the athlete may develop acute loss of postural tone, hypotension, and therefore transient global cerebral hypoperfusion – this is termed the Bezold-Jarisch reflex. Contributing factors likely include dehydration and reduction in plasma volume. Syncope immediately post-exercise which occurs when the subject is still standing, is usually less concerning than syncope during exercise.

Syncope which occurs during exercise raises concern for structural heart disease and can serve as the only symptom that precedes sudden cardiac death. The differential diagnosis for life-threatening causes of syncope in athletes includes hypertrophic cardiomyopathy (HCM), anomalous coronary artery, arrhythmogenic right ventricular dysplasia (ARVD), ion channelopathies such as Long QT Syndrome (LQTS) or the Brugada Syndrome, myocarditis, and even previously undiagnosed congenital heart disease such as noncompaction cardiomyopathy. Although not necessarily associated with underlying native structural heart disease, commotio cordis is an important cause of syncope and is characterized by sudden cardiac death attributable to cardiac contusion from trauma to the precordium. Heat stroke or hyponatremia must also be considered in patients with exercise related syncope.

Although my "symptoms" seemed to start during exercise, it wasn't until I'd stopped exercising (and some small amount of time later, in particular, after stopping all movement altogether and sitting in a chair to rest) that the syncopal episode occurred. That said, given that I had a myocardial infarction (heart attack) just over two months prior, it's still cause for concern, although apparently not really to the cardiology group (having observed my ECG over two days in the hospital and performed a tilt-table test prior to discharge). But it was concerning enough to the cardiac rehab center that they didn't want me to return until they had direct confirmation from the cardiologist that I was approved to resume cardiac rehab. In general, it seems the cardiac rehab team are more concerned about the episode than the cardiologist group; in fact, it turns out, they had been monitoring my case remotely throughout the day on Monday after I was taken to the ER via ambulance. A short, expensive ride (although the ambulance claim hasn't been submitted to my health insurance yet). Also, there was a period during the syncope of bradycardia, which can be quite alarming; for about 24 seconds, my heart rate was about 20 beats per minute. That's one beat every 3 seconds. And it dropped to that from over 100 bpm very quickly; and after about 24 seconds, just as quickly rose back up to over 100 bpm. But, near as I can tell, I think that's not necessarily uncommon with vasovagal syncope, but it is a bit disconcerting when you see it on an ECG (I was being monitored at the cardiac rehab center at the time of the episode).

All that said, overall, I think I'm doing well. We'll see Monday how it goes on my return to cardiac rehab; I do plan to take it a little easier than I had last week, and will follow whatever guidelines the cardiac rehab staff want to put in place. I can tell you this: I will be tired Monday morning, even before the exercise begins, since Daylight Saving Time starts this Sunday, so Monday will only be day #2 in the "earlier to rise" setting (so, doubly-early: earlier than I used to rise before starting cardiac rehab, and earlier than the prior week by an hour due to DST). I think I may end up in bed much earlier Monday evening than usual.

As for the deductibles, I really wish preventive appendectomies were a thing. I would sign up the whole family. And maybe go ahead & take out anything else that might be a future issue waiting to happen: gallbladder, one of the kidneys, a tonsils if they haven't been done... let's get all the things done while it's on the dime of my insurance instead of me. After all, the Dec 31 timing of the heart attack meant twice the deductible in early 2021 (because of starting and finishing 2020's deductible all on the last day of 2020, to be paid in 2021). Fortunately, it's better than the $63k that was billed for the initial heart attack, along with the over $6k for the episode last week, and the more than $5k for cardiac rehab (when all is said and done). We'll be OK, and surprisingly, we've managed to get some of our credit paid off over the last year plus. Eating in seems to be a lot cheaper than eating out (not to mention much, much healthier!). Also, I promise you, my wife is going to be blogging about all of this in the not-too-distant future, too; she's very busy recently (what with caring for a cardiac patient, learning about cooking low sodium and low saturated fat and all the other things, attending cardiac rehab three days a week as my "heart mate" - at a much lower cost than my own attendance, and going to school to study elementary education with an eye on becoming a teacher in the future... she's super-busy! but she's been noting things down, and considering plans, and we'll get her a blogging address set up for her to put to the public everything she's learned, tips and tricks, helpful suggestions, and general encouragement for those in similar situations).

So... did you hear about the butcher who accidentally backed into his meat grinder? He got a little behind in his work.

Later, all...

1 comment:

Ninfa said...

That joke... 🤣

Cardiac rehab was so phenomenal in how they handled everything that morning!