11. Syncope

Question 1

Syncope distribution

Answer 1

Initial 20-30 and older

Question 2

Syncope ddefn

Answer 2

transient LOC and postural tone with rapid, complet spont recovery (cause by global hypopefusion)

Question 3

3 broad categories of syncope

Answer 3

reflex
orthostatic
cardiac

Question 4

How does reflex syncope occur?

Answer 4

inappropriate vasodilation, bradycardia or both - includes vasovagal, carotid sinus syndrome and situational

Question 5

Vasovagal syncope - how does this occur?

Answer 5

prodrome nausea, pallor, sweat, lightheaded, change in vision

Question 6

Carotid sinus syndrome

Answer 6

pause of >/=3s and or >/=50mm hbg decrease in bp when stimulate carotid sinus

Question 7

Orthostatic hypotension defn

Answer 7

decr bp sbp 20, dbp 10 within 3 min of standing (HR incr 30)

Question 8

Cardiac diagnosis associated with syncope - 2 dysrh

Answer 8

tachydys
bradydys

Question 9

Cardiac diagnosis associated with syncope - structural causes

Answer 9

hcm
ao stenosis
severe pulmonic stenosis
ac MI
cardiac masses like myoma
pericrdial tamponade
prosth valve dysfunc
vad dysfunc

Question 10

Cardiac diagnosis associated with syncope - 3 cardiopulmonary causes

Answer 10

ac ao dissection
pe
phtn

Question 11

Name 5 bradyarrh associated with syncope

Answer 11

ABblock mobitz 2 and III
sinus pause >3s
sick sinus syndrome
persistent sinus brady <40s

Question 12

Name 5 tachydysrh assoc with syncope

Answer 12

vent tachy: Monomorphic, polymorphic, vent fib
SVT: afib/flutter, AVNRT, AVRT
Alt L and RBBB
PM or ICD malfunc

Question 13

ECG abnormalities potentially associated with syncope

Answer 13

signs of AMI
Pre-excitation of wpw
long qtc
short qt
RBBB with brugada
inverted t wave in R precordial leads and epsilon waves sugg of arrhthmogenic RV cardiomyopathy
LVH, abn q wabes or deep inverted HCM
RV strain pattern suggestive of PE

Question 14

Syncope mimics

Answer 14

mechanical fall
intxoication
hypoglycemia
hypoxemia
head truama - concussion
seizures
tia
cataplexy
drop attack
psychogenic syncope

Question 15

What medications are assoc with orthostatic hypotension:

Answer 15

1. Vasodilators:
   Beta blockers, calcium channel blockers, nitrates, hydralazine, angiotensin-
   converting enzyme inhibitors, angiotensin receptor blockers, phenothi-
   azines, phosphodiesterase inhibitors (e.g., sildenafil, tadalafil)
   Diuretics (e.g., hydrochlorothiazide, furosemide)
   Central antihypertensives (e.g., clonidine, methyldopa)
   QT-prolonging agents (e.g., amiodarone, flecainide, procainamide, quini-
   dine, sotalol)
2. Psychoactive agents:
   Anticonvulsants (e.g., carbamazepine, phenytoin)
   Antipsychotic drugs (e.g., olanzapine, risperidone)
   Antiparkinsonian agents (e.g., levodopa, pramipexole)
   Central nervous system depressants (e.g., barbiturates, benzodiazepines) Antidepressants (e.g., monoamine oxidase inhibitors, Selective serotonin
   receptor reuptake inhibitors, trazodone, tricyclic antidepressants) Opiates analgesics (e.g., morphine)
   Sedating antihistamines (e.g., diphenhydramine)
   Cholinesterase inhibitors (e.g., donepezil, tacrine, galantamine) Alcohol
   Digitalis
   Neuropathic agents (e.g., vincristine) Bromocriptine

Question 16

Routine laboratory testing, although often done for patients with syn- cope,…? recommended?

Answer 16

is not supported by evidence and is not recommended in national guidelines.

Question 17

Critical diagnoses assoc with syncope: list 8

Answer 17

Myocardial infarction
Life-threatening dysrhythmias
Acute aortic dissection
Critical aortic stenosis
Hypertrophic cardiomyopathy Pericardial tamponade
Abdominal aortic aneurysm (ruptured)
Massive pulmonary embolism Subarachnoid hemorrhage Toxic-metabolic derangements Severe hypovolemia or hemorrhage
Ruptured ectopic pregnancy
Sepsis

Question 18

Systemic Hypoperfusion Resulting in Central Nervous System Dysfunction
Cardiovascular System–Mediated:
Outflow Obstruction

Answer 18

Mitral, aortic, or pulmonic stenosis Hypertrophic cardiomyopathy Atrial myxoma
Pulmonary embolism
Pulmonary hypertension Cardiac tamponade Congenital heart disease

Question 19

Systemic Hypoperfusion Resulting in Central Nervous System Dysfunction
Cardiovascular System–Mediated:
Reduced CO - tachy

Answer 19

Supraventricular tachycardia Ventricular tachycardia Ventricular fibrillation Wolff-Parkinson-White syndrome Torsades de pointes

Question 20

Systemic Hypoperfusion Resulting in Central Nervous System Dysfunction
Cardiovascular System–Mediated:
Reduced CO - brady

Answer 20

Sinus node disease
Second-degree and third-degree atrioventricular block Prolonged QT syndrome
Brugada syndrome
Pacemaker malfunction
Implanted cardioverter-defibrillator malfunction

Question 21

Systemic Hypoperfusion Resulting in Central Nervous System Dysfunction
Cardiovascular System–Mediated:
Reduced CO - other CVD x3

Answer 21

Aortic dissection
Myocardial infarction Cardiomyopathy

Question 22

DDX vasovagal neurally medial

Answer 22

Reflex syncope (vasovagal): Emotion
Pain Instrumentation
Valsalva—elevated intrathoracic pressure, weightlifting; tussive, sneeze Situational
Carotid sinus sensitivity (necktie, shaving syncope) Post-exercise
Gastrointestinal—swallowing, vomiting, defecation Post-micturition

Question 23

Focal hypoperfusion of nervous system causing syncope ddx

Answer 23

Cerebrovascular disease Hyperventilation Subclavian steal Subarachnoid hemorrhage Basilar artery migraine Cerebral syncope
Central Nervous System Dysfunction With Normal Cerebral Perfusion Hypoglycemia
Hypoxemia—asphyxiation
Seizure
Narcolepsy Psychogenic
Anxiety disorder Conversion disorder Somatization disorder Panic disorder Breath-holding spells
Intoxication Medications
Carbon monoxide Undetermined causes

Question 24

Recommended tests for syncope

Answer 24

glucose
ecg
hx and pe
labs per hx and pe

Question 25

Canadian syncope risk score

Answer 25

1. Predisposition to vasovagal syncope −1
2. History of heart disease +1
3. Any systolic pressure reading in the emergency department <90 or >180
   mm Hg +2
4. Troponin level >99th percentile for normal population +2
5. Abnormal QRS axis (<−30 degrees or >110 degrees) +1
6. Prolonged QRS interval >130 ms +1
7. Prolonged corrected QT interval >.480 ms +2
8. Emergency department diagnosis of vasovagal syncope −2
9. Emergency department diagnosis of cardiac syncope +2
   Score of −2 is very low risk, −1 or 0 is low risk, 1–3 is medium risk, and >3 is high risk

Question 26

FAINT score syncope

Answer 26

1. History of heart failure +1
2. History of cardiac arrhythmia +1
3. Initial abnormal 12-lead ECG result +1
4. Elevated N-terminal pro b-type natriuretic peptide (NT proBNP) >125 pg/mL
   +2
5. Elevated high-sensitivity troponin T >19 ng/L +1

Question 27

San Francisco Syncope Risk Score

Answer 27

1. History of congestive heart failure
2. Hematocrit <30%
3. Abnormal findings on 12-lead ECG or cardiac monitoring 4. History of shortness of breath
4. Systolic blood pressure <90 mm Hg at triage

Question 28

Short term RF for syncope

Answer 28

1. Older age
2. Male gender
3. Family history of early sudden death (under 50 years old) 4. Syncope without prodrome
4. Exertional syncope
5. Syncope while in supine position
6. Palpitations before syncope