3.3.3. Syncope

Question 1

Standing in line for a long period of time can predispose to venous pooling, leading to … what?

Answer 1

Standing in line for a long period of time can predispose to venous pooling, leading to vasovagal syncope

Question 2

CAD is the leading risk factor for …

Answer 2

CAD is the leading risk factor for ventricular tachycardia

Question 3

Major injury = think _________ causes of syncope (except with elderly patients)

Answer 3

Major injury = think cardiovascular causes of syncope (except with elderly patients)

Question 4

_______ = postictal confusion, tongue biting, bladder AND/OR bowel incontinence, family history of epilepsy, or repetitive tonic-clonic movements

Answer 4

Seizure = postictal confusion, tongue biting, bladder AND/OR bowel incontinence, family history of epilepsy, or repetitive tonic-clonic movements

Question 5

History of MI = _________ ________

Answer 5

History of MI = ventricular tachycardia

Question 6

Syncope during exercise or family history of sudden death = what (2 options)

Answer 6

Syncope during exercise or family history of sudden death = LQTS or HCM (long QT syndrome or hypertrophic cardiomyopathy)

Question 7

Newly prescribed medications = ______ ________

Answer 7

Newly prescribed medications = orthostatic hypotension

Question 8

>20 mmHg drop in systolic or >10 mmHg drop in diastolic blood pressure after standing for 3 minutes confirms this type of hypotension

Answer 8

Orthostatic

Question 9

Valvular aortic stenosis is most common in the elderly and, when associated with syncope, may indicate a very high risk for what?

Answer 9

Valvular aortic stenosis is most common in the elderly and, when associated with syncope, may indicate a very high risk for sudden cardiac death

Question 10

LOC when rising from a squatting position or after exertion (dehydration) = _____ ______ ______

Answer 10

LOC when rising from a squatting position or after exertion (dehydration) = neurally mediated syncope

Question 11

The following is a description of events following which kind of syncope?

Before event: nausea and progressive loss of vision = autonomic activation

After event: fatigue, nausea, and the desire to void = autonomic activation

However, the absence of premonitory or post-dromal symptoms is fairly common in the elderly

Answer 11

Neuronally mediated syncope

Question 12

Chest pain or LOC while walking = ______ _____

Answer 12

Chest pain or LOC while walking = cardiovascular syncope

Question 13

Most common causes of cardiac syncope in children are … (2 causes)

Answer 13

Most common causes of cardiac syncope in children are LQTS and HCM

On ECG look for prolonged QT and/or left ventricular hypertrophy

If syncope occurs during exercise, then it is cardiovascular until proven otherwise

Question 14

The most common cause of syncope in children = what?

What subset of children is this most common in?

Answer 14

The most common cause of syncope in children = vasovagal episode

Especially among adolescent females

Question 15

In syncope patients, what are you looking for in the general inspection of the chest?

Answer 15

General Inspection of Chest (shirt off)

Look for shortness of breath and surgical scars

Question 16

What are you looking for when you inspect a syncopal patient’s hands?

Answer 16

• Inspect the Hands
  
  • Symmetrically warm; no sign of tar staining on the fingernails; no splinter hemorrhages; no sign of finger clubbing
  • Pallor (unhealthy pale appearance) = sign of anemia
  • Assess pulse rate (one side) and then check for bilateral pulse rate
    
    • Radial-Radial delay = aortic coarctation
  • Check pulse while lifting arm up in the air
    
    • Collapsing pulse = aortic regurgitation

Question 17

When recording blood pressure for syncopal patients, what is one special thing you must do?

Answer 17

Record Blood Pressure [note any difference b/w sitting and standing]

Allow 3 minutes of standing to assess orthostatic pressure

Question 18

In syncopal patients, what are you looking for in their jugular venous pulse?

Answer 18

Assess Jugular Venous Pressure

Palpate carotid pulse (lean head back gently) (only after checking for bruits!)

Looking for “normal character and good volume”

Question 19

Along with the general inspection of the chest, what are you looking for in the patient’s face?

Answer 19

• Inspect the Face
  
  • Xanthelasma = hypercholesterolaemia; corneal arcus = hyperlipidaemia; conjunctival pallor (peal down eyelid) = anemia
  • Malar flush (cheeks) = mitral stenosis
  • Poor dental hygiene = infectious endocarditis

Question 20

When looking (and palpating) closer at the patient’s chest, what might you find?

Answer 20

• Close Inspection of the Chest
  
  • Visible pulsations at the apex of the heart = ventricular hypertrophy
  • Palpation
    
    • Apex beat (5th Intercostal space, Midclavicular line)
    • Feel for heaves and thrills (mitral/tricuspid areas, aortic/pulmonic areas)
      
      • Thrills = palpable murmurs
      • Heaves = ventricular hypertrophy

Question 21

For auscultation, what are a couple of special maneuvers to check for certain heart murmurs?

Answer 21

• Auscultation
  
  • Apex (feel carotid pulse to identify the 1st and 2nd heart sounds)
    
    • Mitral; Tricuspid; Pulmonary; Aortic
  • Listen for carotid bruits (head back and hold breath)
    
    • Palpate carotid pulses individually if no bruits
  • Lean forward, deep breath in and exhale all the way out
    
    • Aortic regurgitation [listen w/ diaphragm in aortic/pulmonic areas]
    • Check for mitral stenosis by asking the patients to lay on their L side & auscultating at the apex with the bell of your stethoscope
    • Auscultate lung bases

Basal crackles = heart failure

Question 22

Where do we look for edemas and what might they indicate?

Answer 22

Feel for sacral edema (heart failure) and pedal edema

Question 23

What is syncope and what may cause it?

Answer 23

1. Syncope is sudden loss of consciousness and postural tone not due to epileptic seizures or trauma with spontaneous recovery
   
   1. Usually due to a brief interruption of blood flow to the brain followed by immediate restoration of flow
   2. Transient fall in cardiac output or loss of vascular tone

Question 24

What kind of patients undergo syncope and what are some mortalities related to cardiovascular related syncope and unkown origin syncope?

Answer 24

Patients with syncope range from perfectly healthy to those at risk for immediate sudden cardiac death

Syncope due to cardiovascular disease = one-year mortality of 20-30%

Unknown or noncardiovascular syncope = 5% one-year mortality

Question 25

Key finding in approaching the Syncopal Patient is differentiating _______ from ________ syncope

Answer 25

Key finding in approaching the Syncopal Patient is differentiating cardiovascular from noncardiovascular syncope

Question 26

What are some of the electrical issues seen with cardiovascular syncope?

Answer 26

1. Electrical Instability (common in elderly patients)
   
   1. Ventricular tachycardia should be suspected in anyone with syncope and a history of MI, no matter how remote in time
      
      1. Post MI, Congenital and Drug-Induced Long QT syndrome
   2. Ventricular Fibrillation (Acute MI, Hypertrophic Cardiomyopathy)
   3. Supraventricular Fibrillation

Bradyarrhythmias (Sick Sinus Syndrome; Tachy-Brady Syndrome; Complete Heart Block)

Question 27

What are some of the mechanical issues that can cause syncopal episodes?

Answer 27

1. Mechanical Obstruction
   
   1. Aortic Stenosis (valvular or infravalvular)
   2. Concentric Left Ventricular Hypertrophy
   3. Pulmonary embolus
   4. Atrial Myxoma
   5. Subclavian Steal Syndrome

Question 28

Neurally mediated syncope accounts for __ % of cases

Answer 28

Neurally mediated syncope accounts for 52% of cases

Question 29

What are a couple of syncope classifications for neuronally mediated syncope?

Answer 29

1. Several Classifications
   
   1. Vasodepressor
      
      1. Effect is primarily on vascular tone resulting in vasodilation and loss of blood pressure
   2. Cardioinhibitory
      
      1. Effect causes bradycardia
   3. Typically see both

Question 30

Describe the vasovagal faint.

Answer 30

1. Common Faint (vasovagal faint)
   
   1. A type of neurally mediated syncope referred to as “vasovagal” episode
   2. Occurs in the setting of pain or emotional stress
      
      1. Prodromal symptoms: nausea, weakness, flushing, lightheadedness, and pallor
      2. Experience weakness and fatigue for hours or even days afterwards
   3. Dehydration or venous pooling in the extremities greatly enhances the likelihood of syncope
      
      1. Predisposing factors also include fatigue, hunger, and a hot humid environment

Question 31

Describe the micturition syncope.

Answer 31

1. Micturition syncope
   
   1. Lose consciousness after straining to void (valsalva maneuver), usually after a night’s sleep
   2. Placing patients on a Tilt Table at 60 degrees reproduces symptoms (nucleus tractus solitarius)

Question 32

What kind of syncope can be caused by shaving?

Answer 32

1. Carotid sinus hypersensitivity
   
   1. Classically described in elderly men while shaving

Question 33

What kinds of things predispose a patient to orthostatic hypotension?

Answer 33

1. Orthostatic (Postural) Hypotension
   
   1. Occurs while patient is standing up
   2. Predisposing factors include: Parkinson’s, Shy-Drager, diabetes, antihypertensive vasodilator drugs, and prolonged bedrest

Question 34

What kind of drugs may induce a drug induced syncope?

Answer 34

1. Drug induced syncope
   
   1. Nitroglycerin (vasodilator of veins and arteries), Diuretics, alpha-blockers

Question 35

Why is finding a history of sudden death important in syncopal patients?

Answer 35

1. Family history of sudden death
   
   1. Unexplained death (even drowning) or history of syncope in a sibling may indicate an inherited disorder
      
      1. Long QT syndrome (LQTS; an ion channel disorder resulting in ventricular tachycardia)
      2. Hypertrophic Cardiomyopathy (HCM)
         
         1. Both disorders are autosomal dominant

Question 36

What is important to gain from the patient history regarding the syncopal episode itself?

Answer 36

1. Description of setting, premonitory symptoms, presence of post-syncopal confusion, incontinence, neurologic dysfunction
   
   1. Comparison with a bystander history

Question 37

What is the difference between having a syncopal episode during versus around exercise?

Answer 37

Syncope after exercise may be due to a vasovagal episode, but syncope during exercise is very worrisome and may indicate a significant propensity for sudden death such as HCM or LQTS

Question 38

Why do we need to be careful in retrieving a history of cardiac disease in syncope patients?

Answer 38

1. A careful past medical history for evidence of cardiac disease is essential
   
   1. Chest pain, infarction, heart failure, valvular disease, or multiple cardiac risk factors identifies a patient at high risk
      
      1. Palpitations prior to syncope = tachyarrhythmia
      2. Ventricular tachycardia frequently have no premonitory symptoms
   2. Absence of premonitory symptoms is worrisome for arrhythmia
      
      1. Patients who are injured during syncope are more likely to have had a cardiovascular cause of syncope
         
         1. Elderly can be injured during syncope of any kind
   3. High risk occupation = pilots, school bus drivers, etc.
   4. Medication
      
      1. BP medication are prone to cause orthostatic hypotension
         
         1. Common noncardiac cause of syncope in the elderly

Question 39

How do you report a patient initially to an attending?

Answer 39

THIS IS A (age) YEAR OLD (race) (gender) WITH (if highly relevant: concurrent medical problem), WHO PRESENTS (reason for presentation & duration)

Question 40

How do you report a patient’s baseline health to an attending?

Answer 40

THE PATIENT WAS IN HIS/HER USUAL STATE OF (good, compromised) HEALTH (symptoms/able to do what) UNTIL (when). NOW THE PATIENT PRESENTS WITH COMPLAINS OF (symptoms**: provide details of current episode)

Question 41

How do you present the symptoms of a patient to an attending?

Answer 41

1. Start at the beginning of the illness and proceed chronologically
2. Use OPQRST
   
   1. Onset, Provoking Factors, Quality, Region/Radiation, Symptoms/severity, Temporal aspects
3. Associated symptoms or associated risk factors
4. Include “pertinent negatives”
5. Do not forget important aspects of:
   
   1. PMHx, PSHx, Meds, Allergies/Immunizations, SHx, FamHx, ROS
   2. Cardiovascular ROS
      
      1. Have you had any chest pain; have you been short of breath (with exertion = dyspnea on exertion, while lying flat = orthopnea, suddenly while sleeping = paroxysmal nocturnal dyspnea); have you had any palpitations; have you had any swelling in your legs or feet (edema); have you had any pain in the calves while walking (claudication)?

Question 42

What is your summary statement to an attending going to look like?

Answer 42

1. Brief, one sentence summation of only the most critical two or three details from the H&P
2. First time in the presentation where you tie together the facts you feel strengthen your opinion of the correct diagnosis into one coherent thought