Autonomic Medicine in Cardiology with Howard Snapper, MD

Mr. Al Ruechel: Hello everyone, I’m Al Ruechel. We continue our series; we want to thank you for joining us here on the internet. We’re going to talk about autonomic medicine in cardiology and my guest is doctor Howard Snapper. Doctor Snapper thank you so much for stopping by, appreciate it.

Dr. Howard Snapper: Thanks for having me.

Mr. Ruechel: Give me a little bit of your background, your bio if you want to put it like that.

Dr. Snapper: Sure, well I am an interventional cardiologist by training, and I’ve been doing general cardiology and angioplasties, stents, pacemakers, and all that for many years and then about ten years ago I started getting involved in this autonomic medicine. So, I took an interest in it because of the fact that there was so many patients that would come to cardiologists with heart symptoms, but their testing would all be normal. And the patients would all be very frustrated because they would have chest pain, shortness of breath, palpitations, dizziness or fainting and yet everything came out normal. So, I’m pretty persistent so instead of giving up I kept looking and trying to find a reason for a reason for why they were having it and ultimately, I was able to find the cause which turned out to be in the autonomic realm.

Mr. Ruechel: Ok, so the cause, let’s talk more about it specifically if you could.

Dr. Snapper: Ok, so basically a lot of the stuff, in the most simplistic way, a lot of it is sort of adrenaline based. So, the sympathetic nervous system is part of the autonomic system that produces our norepinephrine and our epinephrine and for whatever reason that system is firing, that causes a lot of different symptoms. For example, it would increase the heart rate or cause the patient to have palpitations or the feeling their heart pounding, it can cause dizziness, it can cause chest pain and usually it’s not actual pain from their heart but a lot of the time it’s actually their chest wall or their chest itself is contracting because of the epinephrine and norepinephrine and so they feel tightness and they think it’s their heart when in fact it’s not a heart issue. But they still feel that, and in the same sense there’s also difficulties with breathing and patients also have difficulty with feeling like they are going to faint or fainting because of all of this.
Mr. Ruechel: And because if you watch tv or read the newspaper and we’re told if you have any of those symptoms go the ER because you may be having a heart attack.

Dr. Snapper: That’s exactly right, and a lot of those patients, we meet them a lot in the emergency room because they do come to the hospital because of those things and we find them and we evaluate them and a lot of the times they get heart testing, usually whether it’s in the hospital or back in the office they’re going to get a stress test, or they are going to get an echocardiogram, which is an ultrasound of their heart, or they are going to get something some sort of heart monitor to look at their heart rhythm and so many times these all comeback negative. And most cardiologist you know they get to the point where they say well it’s not your heart so I’m not sure what the next step is and that’s sort of where I got into this.

Mr. Ruechel: Ok, so then let’s play this all of the way out then. So, then what is the next step for people, ER doctors they go, “We can’t figure out what’s going on”.

Dr. Snapper: Well, the next step in the first place, which I think is the most important thing is to not underestimate the patient. The patient is not making up these symptoms and I think a lot of times healthcare providers in general sort of just get frustrated with the patient because they say we’ve done everything and it’s probably just anxiety. And I call just a four-letter word because it’s almost like you’re talking down to the patient when you say it’s nothing it’s just anxiety and it’s usually not anxiety, actually, there is a lot of other things that play into this. Sometimes it actually is anxiety but that’s sort of the less common of the causes.

Mr. Ruechel: Yeah, my son is an ER doctor so he will tell you when you look at the statistics you have most of the people who are coming in that are being treated, besides injuries, are often times being treated for behavioral issues or a psychological issues that may manifest themselves in cardiology problems.

Dr. Snapper: Absolutely, that is correct.

Mr. Ruechel: So, now we get to the quandary of well then how do you take it to the next step because in the ER, it would be nice if you would go to your primary care physician they would look at it, but oftentimes people come to the ER and they say you don’t have a heart attack, well it still hurts and they go home and they don’t do anything.

Dr. Snapper: Well, at that point they have to go to somebody at least who has an idea what the next steps are in evaluating the patient and then treating them. Because there are many treatments, but you first have to figure out what the patient has.

Mr. Ruechel: Ok, with autonomic problems then we’ve talked about the next steps. So, the heart is involved when do you make the determination that, “Ok, you don’t have a heart attack and you’re not going to die”?

Dr. Snapper: It’s a great question, so once a patient in the first place if we really suspect a heart attack, we’re going to draw blood tests in the hospital, cardiac enzymes they’re called, and we’re going to make sure those are normal. If those are normal then the next step is often the patient will often have a stress test to make sure there is no abnormality that suggests that they have an obstruction of blood flow in the heart again we may do an echocardiogram to make sure there is no heart dysfunction or valve dysfunction that could cause shortness of breath and at that point once everything else is negative then the patient will go home. But then, at that point the next step is where do they go next if they continue to have symptoms.

Mr. Ruechel: Yeah, and this still falls under the umbrella of a dysautonomia is that correct?

Dr. Snapper: Well, so ultimately those patients will ultimately come to me and part of my evaluation before I even see the patient is I have them fill out a questionnaire. And one of the greatest things to figure out if they have a dysautonomia is getting this questionnaire and looking at it. And basically I cover heart symptoms, but I also cover GI symptoms, urinary symptoms, neurologic symptoms, do they have migraine headaches, do they have urinary symptoms do they have too much sweating, do they not enough sweating, do they have problems sleeping and I take this inventory and then I look at it and basically it’s a paper form at this point and when I look at it before I even go into the room when they’ve checked off every box I know that they probably have a dysautonomia.

Mr. Ruechel: Probably because it involves so many of the systems. Now, as a trained cardiologist let’s say you rewind the clock and go back to school. Do they tell you what you do when you have multiple systems automatically involved with the heart or what?

Dr. Snapper: That’s a great question, so first place none of this is taught in medical school, none of this is taught in cardiology, none of this is taught in really in medicine.

Mr. Ruechel: Still not taught?

Dr. Snapper: To this day, and I talk to my residents all the time when I see them and I say I anyone talking about this and they say no, no one teaches this stuff. So, the thing is, is that key concept is most people don’t have time to ask all of the other questions. So, they don’t know the patient’s having stomach issues and their having urinary issues and their having sleep issues, etc. So, if you focus just on the heart symptoms once you’ve done all the evaluation that we do for the heart symptoms you’re basically finished because you say I’ve done everything and there’s nothing more I can do for you so you need to go find somebody else to help you. But, the thing is if you look at these other systems and you realize it’s a pattern going on, that they have all of these other issues going on together that’s when it becomes clear that they may have an autonomic disorder and that’s when I do a further work up.

Mr. Ruechel: So, I don’t want to use the word failure, but if the system needs to be corrected does the fifteen minute office visit need to be one of those areas that needs to be corrected because I’m hearing from so many doctors that it really is that patient history that is really, really key.

Dr. Snapper: The history is the most important part of this entire thing, testing is just sort of supporting what you feel based on the history but the problem is the fifteen minute exam, my fifteen minute exams are usually forty-five minutes to an hour, which really makes a dent on my schedule but it’s very difficult because these patients are not simple, these patients are very complicated and they have multiple issues that they’re dealing with.

Mr. Ruechel: Yeah, don’t they have the right to expect that they are going to get the kind of care that helps them identify, apart from the people who come in and demand and say I know I’ve got a heart problem blah blah blah blah.

Dr. Snapper: No, they absolutely do, it’s just a matter of resources and time. So, I think a lot of these patients come in and you know what I do, I expect them to be a relatively long visit and I schedule it, or I try to schedule it appropriately so I’m not running too late for my next patient but it takes a lot of patience to do what I do because you have to sit and you have to listen and a lot of these patients have had issues going on for five, ten, fifteen, twenty, or more years so they want to tell you their whole story from the very beginning so what I’ve leaned over time is how to try to direct them so I bring them sort of to today present and see what’s going on now, but it’s important to hear some of these old stories because they may have fainting since they were a child or they may have other issues involved.

Mr. Ruechel: As they say we’ve heard one doctor say, “The proof is in the pudding”. So, the pudding is that you’ve been now been evaluating people differently based on what you know is the proof there that it works in terms of yes we are discovering what these people really have.

Dr. Snapper: Absolutely, I think because, well the proof in the pudding is a fact that once I figure out what they have and I start treating with the certain therapies, depending what it is, most of them get better, not all of them , but a majority of them will get improvements and that’s the important thing.

Mr. Ruechel: And that’s what people need to hear. Now, what about anything dealing with the heart and it not working properly as a function of age. Do we see this more in younger people, teenagers, adults what?

Dr. Snapper: So, if it truly is a heart issue there is certainly is certainly more heart issues as we get older, either with atherosclerosis where we get blockages in the blood vessels, we could have heart valve dysfunction, we can have high blood pressure, we can have heart dysfunction, congestive heart failure, and things like that. So, all of those things I’m evaluating for along the way to make sure they don’t have an organic heart problem meaning a heart problem that’s an actual heart problem. Do they just have the symptoms, or do they actually have an actual heart problem, in which case I am going to treat that part of it as well.

Mr. Ruechel: Yeah, so, a couple last things we want to do, number one talk to doctors, what do they need to know as a cardiologist.

Dr. Snapper: Well, one of the most important things is to ask the questions. Sometimes it opens up a pandora’s box but really, but really you want to know if they’re having other issues, are they having other symptoms and in particular are they having other related disorders for example, as far as gastrointestinal disorders, patients will have functional gastroparesis, where they will eat food and get full very easily or they can only eat small meals, they have a lot of nausea or vomiting and they may have irritable bowel syndrome, they may have migraine and headache disorders, they may have interstitialitis, which is a urinary disorder and all kinds of these other related disorders that all fall under the same umbrella because it’s the same underlying cause that’s causing the problem. And so, I think that number one it’s important to at least find out if they’re having other things. One of the other things that’s very important, at least in my practice is finding out if the patients, and this is a question the patients often find odd, but a lot of the patients who have, you’ve probably heard today POTS, postural orthostatic tachycardic syndrome, so a lot of those patients have disorder underlying called hypermobility or Ehlers Danlos Syndrome, and so if you ask the patients if they’re double jointed or if they’ve had multiple joint dislocations or joint issues, surprisingly a lot of them will tell you yes and then you can follow a different pathway, because those patients are very susceptible to having an autonomic dysfunction. So, it’s very important to ask these questions that seem bizarre, but they are actually related to what is going on with the patient.

Mr. Ruechel: Yeah, great, doctor thank you so much for your time and good luck in your practice.

Dr. Snapper: Oh, my pleasure, thank you very much.