Cardiac Clinical Medicine Part 4: Syncope and Chronic Hypertension

Question 1

What is syncope?

Answer 1

A transient, self-limited loss of consciousness due to cerebral hypoperfusion

Question 2

What are the three categories of syncope?

Answer 2

1) Neurally mediated syncope
2) Cardiac syncope
3) Orthostatic hypotension

Question 3

What are some common syncope mimics?

Answer 3

1) Seizurie
2) Sleep disturbance (narcolepsy)
3) Head trauma

Question 4

What are the causes of syncope?

Answer 4

Reduced cardiac output and impaired oxygenation

Question 5

What are the prodrome symptoms of neurally mediated syncope?

Answer 5

1) Abdominal pain
2) Diaphoresis
3) Blurred vision
4) Dizziness
5) Slowed pulse

Question 6

Orthostatic hypotension occurs when there is reduction in systolic BP of?

OR

Diastolic BP of?

Answer 6

1) 20 mmHg or more

2) 10 mmHg or more

Question 7

Orthostatic hypotension causes lightheadedness/dizziness when?

Answer 7

With sudden postural change

Question 8

What are the prodrome symptoms of cardiac syncope?

Answer 8

1) Chest pain

2) Palpitations

Question 9

If a patient with syncope shows an absence of focal neurological findings what testing has no benefit?

Answer 9

1) MRI and CT of the head

2) Carotid artery imaging

Question 10

What type of syncope is tilt table testing useful for?

Answer 10

Reflex syncope (Type of Neurally mediated syncope)

Question 11

When do we want to use stress testing?

When do we want to use transthoracic echocardiogram?

When do we want to use electrophysiology studies?

Answer 11

1) Patients with exertional syncope
2) Suspected structural disease
3) Suspected arrhythmia

Question 12

What device is used when a patient presents with cardiac symptoms that recur within 24-72 hours?

When symptoms recur within 2-6 weeks?

When symptoms are recurrent, infrequent, or have unexplained syncope of suspected arrhythmic origin?

Answer 12

1) Holter
2) Event monitor or external loop recorder
3) Internal monitor

Question 13

What is the goal of treatment/management of neurally mediated syncope?

What is done to accomplish this?

Answer 13

1) Increase central blood volume and cardiac output

2) Physical counterpressure maneuvers of the limbs (leg crossing or handgrip and arm tensing)

Question 14

What should be done in the treatment/management of syncope due to orthostatic hypotension?

Answer 14

Remove reversible causes (most commonly medications)

Question 15

What should be done in the treatment/management of cardiac syncope due to bradyarrhythmias?

Due to tachyarrhythmias?

Answer 15

1) Cardiac pacing

2) Ablation, antiarrhythmic drugs, and cardioverter-defibrillators

Question 16

Smoking, DM, hypercholesterolemia, obesity, lack of exercise, and poor diet make up what risk factors for HTN?

CKD, family history, older age, male sex, and obstructive sleep apnea make up what risk factors for HTN?

Answer 16

1) Modifiable risk factors

2) Relatively fixed risk factors

Question 17

What is the most common cause of death in HTN patients?

What are examples of the above answer?

Answer 17

1) Heart disease

2) LVH, atheroslerotic CAD, and cardiac arrhythmias

Question 18

Elevated BP with no specific underlying disorder is known as?

Elevated BP with a specific underlying disorder is known as?

Severe BP elevation (>180/110) WITHOUT symptoms of end organ damage is known as?

Severe BP elevation (>180/110) WITH symptoms of end organ damage is known as?

Answer 18

1) Primary or “essential” HTN
2) Secondary HTN
3) Asymptomatic severe HTN (AKA “hypertensive urgency”)
4) Hypertensive emergency

Question 19

Elevated BP is defined as?

Stage 1 HTN is defined as?

Stage 2 HTN is defined as?

HTN in pregnant women is defined as?

Answer 19

1) 120-129/<80 mm Hg
2) 130-139/80-89 mm Hg
3) >140/90 mm Hg
4) SBP > 140 or DBP >90

Question 20

What are the lab tests that should be done for HTN?

Answer 20

1) Fasting blood glucose
2) CBC
3) CMP
4) Lipid panel
5) TSH
6) Electrolytes
7) Urinalysis
8) EKG

Question 21

What qualifies a patient as high risk and in need of BP lowering medication even if they are only in stage 1 HTN?

Answer 21

Patients with DM, CKD, or older than 65

Question 22

What is the treatment/management for stage 2 HTN?

Answer 22

Two anti-HTN agents of different classes

Question 23

With the initiation of RAS inhibitors or diuretics in the treatment of HTN what needs to be done?

Answer 23

Assess electrolyte and renal function 2-4 weeks after therapy

Question 24

What are the first line drugs used to treat HTN?

Answer 24

1) RAAS inhibitors
2) CCBs
3) Thiazide diuretics

Question 25

A black HTN patient responds better to what medications?

A white patient?

A DM2 patient?

CHD or CHF?

BPH?

Afib?

Answer 25

1) CCBs or diuretics
2) ACE-I or Angiotensin II receptor blockers (ARBs)
3) ACE-I or ARBs
4) ACE-I or ARBs, β-blockers
5) α-blockers
6) CCBs or β-blockers

Question 26

Benazepril, fosinopril, lisinopril, perindopril, quinapril, ramipril and trandolapril make up what class of drug?

Answer 26

ACE inhibitors

Question 27

Candesartan, irbesartan, losartan, telmisartan, and valsartan make up what class of drug?

Answer 27

Angiotensin II receptor blockers

Question 28

Chlorthalidone and indapamide make up what class of drug?

Answer 28

Thiazide/-like diuretics

Question 29

Amlodipine, isradipine, nifedipine make up what class of drug?

Answer 29

CCBs (dihydropyridines)

Question 30

Atenolol, bisoprolol, carvedilol, and metoprolol make up what class of drug?

Answer 30

β-blockers

Question 31

How do you want to treat Hypertensive urgency?

Answer 31

BP should be lowered gradually <160/100 mm Hg over several days to weeks and then intensify therapy every 2-4 weeks

Question 32

What are the most common signs of HTN emergency?

Answer 32

Cerebral infarction and pulmonary edema

Question 33

What do you want to do when generally treating HTN emergency?

Answer 33

Lower MAP gradually – 10-20% in 1st hour, 5-15% over next 24 hours