B7.010 LG Syncope

Question 1

what is syncope

Answer 1

transient loss of consciousness with loss of postural tone

usually from hypoperfusion of the brain

Question 2

abnormal tilt test

Answer 2

drop in systolic of > 20 or in diastolic of > 10, or experiencing lightheadedness or dizziness is abnormal

Question 3

primary causes of syncope

Answer 3

neutrally mediated reflex (60%)
-vasovagal
-carotid sinus syndrome
-situational (cough, postmicturition)
orthostatic hypotension (15%)
-drug induced
-primary ANS failure
-secondary ANS failure
cardiac arrhythmias (10%)
structural cardiopulm (5%)

Question 4

signs of SNS adrenergic failure

Answer 4

orthostatic hypotension

male ejaculatory failure

Question 5

signs of SNS cholinergic failure

Answer 5

anhidrosis

Question 6

signs of PNS failure

Answer 6

dilated pupils
fixed HR
sluggish urinary bladder
atonic large bowel
male erectile failure

Question 7

hereditary causes of diffuse autonomic neuropathy

Answer 7

familial amyloid polyneuropathy
hereditary sensory autonomic neuropathies
Fabry disease
porphyrias

Question 8

acquired causes of diffuse autonomic neuropathy

Answer 8

1. primary: idiopathic or have autonomic neuropathy as a characteristic feature of the disease process
2. secondary: identifiable cause may lead to autonomic neuropathy
3. neurodegenerative diseases like parkinson’s

Question 9

primary autonomic neuropathies

Answer 9

pandysautonomia
idiopathic distal small fiber neuropathy
Homes-Adie syndrome
Ross syndrome
chronic idiopathic anhidrosis
amyloid neuropathy
postural orthostatic hypotension syndrome (POTS)

Question 10

secondary autonomic neuropathies

Answer 10

diabetes
uremic neuropathy
hepatic disease
B12 def
toxic and drug induced neuropathy
alcohol
infections (Chagas, HIV, leprosy, diphtheria)
autoimmune (celiac, Sjogren, RA, GBS, LEMS, IBD, paraneoplastic)
drug mediated

Question 11

diagnostic testing options for autonomic function

Answer 11

cardiovagal function
sudomotor function
vasomotor function
gastric emptying test
urodynamic tests for bladder function

Question 12

cardiovagal function

Answer 12

HR variability

baroreflex sensitivity

Question 13

sudomotor function

Answer 13

sweat testing (nerves that regulate sweat glands)
thermoregulatory sweat test

Question 14

vasomotor adrenergic function

Answer 14

tilt table testing for orthostatic intolerance

Question 15

non medical management of orthostatic hypotension

Answer 15

hydration, avoid heat
exercises
abdominal binders
tilt up bed
increase salt in diet

Question 16

meds for orthostatic hypotension

Answer 16

B blockers (POTS)
flourinef
midodrine
droxidopa

Question 17

management of autonomic neuropathy

Answer 17

treat the cause
+
symptomatic treatment
digestive: smaller meals, add fiber, laxatives
urinary: hydration, empty bladder frequently at set times, oxybutynin for bladder spasms, bethanechol for bladder emptying
excessive sweating: glycopyrrolate, botulinum toxin
HR: b blockers
sexual: sildenafil, lubricant

Question 18

how do anticholinergics cause orthostatic hypotension

Answer 18

tachycardia leading to decreased venous return of heart
vasodilation with decreased venous return
off target blockage of ganglionic cholinergic transmission
depression of central vasoconstrictor center
typically at high dose

Question 19

postural hypotension w amitriptyline

Answer 19

alpha blockade association
TCAs antagonize:
-M
-a1
-H1

Question 20

Ross Syndrome

Answer 20

cranial postganglionic PNS and SNS dysfunction with autonomic disturbances
triad: tonic pupils, areflexia, anhidrosis
cause unknown, maybe autoimmune
can be progressive

Question 21

neuropathy associated with amyloidosis

Answer 21

bilateral, symmetric, small fiber peripheral neuropathy
generalized autonomic failure
large fibers ok (motor, proprioception)

Question 22

most common systemic amyloidosis

Answer 22

light chain (AL) amyloidosis
caused by plasma cell dyscrasia, not hereditary

Question 23

why can chest/abdominal involvement be seen in length dependent neuropathies

Answer 23

second longest nerves located there (after leg nerves)