Cardiac Clinical Med 4 (Miller) Flashcards
What is syncope?
- A transient, self-limited loss of consciousness due to cerebral hypoperfusion
What are the three categories of syncope?
- Neurally mediated syncope
- Cardiac syncope
- Orthostatic hypotension
What is neurally mediated syncope?
- Transient
- Vasovagal syncope
- Carotid sinus syndrome
- Situation syncope
What is cardiac syncope?
- Due to arrhythmias
What is orthostatic hypotension?
- Chronic Subtypes - Initial - Classic - Delayed - Neurogenic
What are some syncope mimics?
- Seizures
- Sleep disturbance
- Trauma
- Metabolic/toxic disorders
- Psychogenic/pseudo-syncope
What is the clinical presentation of neurally mediated syncope?
- Orthostatic intolerance
- Autonomic activation
- Eyes remain open and deviate upward, pupils dilated
- Urinary incontinence may occur
What is the autonomic activation in neurally mediated syncope?
- Diaphoresis
- Pallor
- Palpitations
- Nausea
- Hyperventilation
- Yawning
What is the clinical presentation of orthostatic hypotension?
- Reduction in systolic BP of > 30 mmHg or diastolic BP > 10 mmHg within 3 min of standing
- Will have lightheadedness, dizziness, and presyncope with postural change
What is the clinical presentation of cardiac syncope?
- Will occur suddenly and with few warning symptoms
- Often while supine or during exertion
How is syncope diagnosed?
- Need a detailed history
- Look for key elements like: history of CV disease
- Medication reconciliation (some meds could be causing)
What testing can be done to help diagnose syncope?
- EKG to look for abnormalities
- CBC w/ electrolytes
- BNP and troponin if suspicious of cardiac cause
What are some different monitors to help track episodes of syncope?
- Holter
- Event monitor
- External loop recorder
- Internal monitor
What would constitute an outpatient stay with syncope?
- Presumed neurally mediated syncope
- Cardiac syncope with no serious condition
What would constitute observation with syncope?
- Age >50
- h/o cardiac disease
- Functioning cardiac disease
- Abnormal ECG
- FH sudden cardiac death
- Symptoms do not point towards neurally mediated syncope
What would constitute admission with syncope?
- Major cardiac arrhythmias
- Serious CV condition
- Noncardiac conditions (severe anemia, major trauma, persistent abnormal VS)
What is the treatment for neurally mediated syncope?
- Increase central blood volume and cardiac output
- Reassurance, avoid triggers and plasma volume expansion with fluid and salt
- Physical counterpressure maneuvers of the limbs
What is the treatment of orthostatic hypotension?
- Remove reversible causes like meds
- Teach patient about moving properly from supine to upright
- Compression stockings and counterpressure maneuvers
- Midodrine or fludrocortisone
What is the treatment of cardiac syncope?
- EPS
- Treat underlying cardiac disorder
What are the modifiable risks of hypertension?
- Smoking
- DM
- Dyslipidemia/hypercholesterolemia
- Obesity
- Inactivity
- Unhealthy diet
What are some relatively fixed risk factors of hypertension?
- CKD
- Family history
- Age
- Socioeconomic status
- Male sex
- Obstructive sleep apnea
- Psychosocial stress
What are some pathological consequences of hypertension on the heart?
- Structural adaptations like:
- LVH
- HF
- Atherosclerotic CAD and microvascular disease
- Cardiac arrhythmias including a fib
What are some pathological consequences of hypertension on the brain?
- CVA
- Impaired cognition/dementia
- HTN encephalopathy
What are some pathological consequences of hypertension on the kidney?
- Renal injury
- ESRD
What are some pathological consequences of hypertension on the peripheral arteries?
- PAD
What is defined as primary HTN?
- Elevated BP with no specific underlying disorder
What is defined as secondary HTN?
- Elevated BP with a specific underlying disorder
What is asymptomatic severe HTN?
- Severe BP elevation (180/110) WITHOUT end organ damage
What is a hypertensive emergency?
- Severe BP elevation (180/110) WITH symptoms of end organ damage
What is defined as normal BP?
- < 120/80
What is defined as elevated BP?
- 120-129/<80
What is defined as stage 1 HTN?
- 130-139/80-89
What is defined as stage 2 HTN?
- > 140/90
What can patients do to help treat and prevent HTN?
- Reduce weight and salt intake
- Adapt to a DASH diet
- Moderation of alcohol consumption
- Physical activity
How do we choose which medications to use in the treatment of HTN?
- Choose based on safety and individual efficacy
- Blacks do better on CCBs or diuretics
- Whites do better on ACEi or ARBs
What should you include in the reassessment of hypertension?
- Detection of orthostasis
- ID white coat effect
- Document adherence
- Monitor response
- Reinforce importance of treatment and assistance in achieving BP target
What is the clinical presentation of someone with HTN emergency?
- Agitation, delirium, stupor, seizures, nausea/vomiting
- Focal weakness, numbness, dysarthria, aphasia
- Visual disturbance, fresh flame hemorrhages, exudates, papilledema
- Chest discomfort, palpitations
- Acute severe back pain
- Dyspnea
What do you do when someone has a HTN emergency?
- Need EKG, CXR, UA, serum electrolytes and creatinine
