Assessment of the CV Patient Palpitations, Syncope and Presyncope

Question 1

Palpitations

• Very common symptom

Answer 1

– Feeling or sensation that heart is pounding or
racing
– Forceful beating
– Awareness of heartbeat
– Skipped beats
• Can be both normal and abnormal
• Regular or irregular

Question 2

see sldie 3

Answer 2

not tested

Question 3

Palpitations: Evaluation

most common AF

Answer 3

• Onset: Sudden or gradual?
• Provokers: Stimulants? Activity? Time of day?
• Quality: Racing? Slow? Regular? Irregular (might be AF)? How fast (>1050 concerned)?
• Relievers: Valsalva (like havong bowel movement, stimulates vagal nerve and slow HR)? Offset – sudden or gradual?
• Severity: Limits activities? Feel physically unwell?
• Timing: How long does it last? When did it start? How often does it happen?
• Associated symptoms: SOB, CP, syncope, presyncope, lightheadedness? (more worried if there are symptoms)
• Pertinent negative: Age (AF older, SVT younger), absence of risk factors
TIP: Pattern of palpitations helps to narrow the etiology

Question 4

• Central Pulses - central will count to every beat

may not feel all pulses if on wrist

Answer 4

Carotid
• Palpation: Reflect aortic valve and ascending aortic function
• Auscultation: bruit, carotid stenosis, cardiac murmur radiation, listening for turbulent blood flow
– Brachial
– Most reliable for measurement of heart rate
• Must be used if patient has atrial fibrillation or an irregular heart rate

• Assess HR, regularity of pulse
– Regular rhythm – count 15 sec x 4 = beats per minute
– Irregular – count 30-60 secs from central pulse, may noy have interval
• Examined for intensity, concordance with the cardiac cycle, rise, fall and volume of pulse

Question 5

ECG

Answer 5

arrhythmia: complexes normal, rhythm (interval) ireggular
AF: no P waves, irregularly irregular (no pattern)
vent fibrillation: quivering
bradycardia: slower rate
tachycardia: faster rate

bp machine may not work due to AF

Question 6

Definitions

syncope
presynchope
lightheadedness

Answer 6

• Syncope
– Sudden, transient loss of consciousness and
posture due to decrease blood flow to the brain
- alarm symptom, med attention needed

• Presyncope
– Lightheaded, muscular weakness and feeling faint
– May or may not precede syncope
- no LOC requring action

• Lightheadedness
Tip: Be careful with words.
Lightheadedness and dizziness may not be the same
thing. (airy light in head vs dizziness is spinning room)
- require little action

Question 7

Syncope:
Differential Diagnosis
just read dont memorize

Answer 7

Cardiac
• Arrhythmia
• Hypertrophic obstructive cardiomyopathy; obstructed flow leaving heart
• Valvular problem

Vasovagal
• Situational, “simple” faint
• Triggered by fear, blood, coughing, pain, etc
• Most common, benign

Orthostatic
• Changes in position
• Often related to drugs, dehydration

Neurologic/ psychiatric

Question 8

Syncope: Evaluation

Answer 8

• Onset: When did the episodes start? Did they happen in childhood?
• Provokers: Situational (Seeing blood)? Change in position? Dehydration? Medications? Over-heated?
• Quality: NA
• Relievers: Can the symptoms be avoided?
• Severity: Have you injured yourself? Do they interfere with your life?
• Timing: How long does the LOC last (true syncope should be fast, when dropping blood get back to brain)? Are the events witnessed?
• Associated symptoms: SOB, CP, presyncope, palpitations, nausea, flushing, sweating?
• Pertinent negative: incontinence (seizure disorder), muscle twitching, confusion, LOC > 1 min, cheek biting

Similar approach to pre-syncope and lightheadedness

Question 9

Postural
Hypotension
- how does it happen?

many causes

endocrine, central, drugs, CV, peripheral

Answer 9

Drop in
SBP > 20mmHg
DBP > 10 mmHg
within 3 minute of standing from supine position

Goals:
Improve symptoms + QOL
(not normalize BP)
see slide 15 infographic

standing -> blood pools in legs -> pooling blood causes reduction in venous return and thus CO, pressure falls -> baroceptors detect drop in bp, increase symp and reduce parasyp outflow (baroreflex) -> peipheral vascular resistance increased causing venous return, CO, BP to increase

• if response is inadequate or delayed, pos hypo can occur

Question 10

Orthostatic Hypotension: Drugs

Answer 10

nitrates
a, b blockers
diuretcs
CCBs
anti-depressant
BDZs
antipsychotics
opioids
trazadone

None are better or worse

Question 11

oth hypo
outcomes
SPRINT

Answer 11

is it associated with CVD, falls, syncope?

expect that lower BP goal would increase CVD, falls, syncope

observed: lower bp goal -> less CVD, no change in falls or syncope

conclusion: not associated with an increased risk of cardiovascular disease falls or syncope., Intensive blood pressure targets did not alter the relationship between OH risk cardiovascular disease.
OH should not be reason to down titrate HTN meds, even in setting of lower BP goal
dont automatically change the pills if you see it