Cardiac- Common PC: Palpitations, Syncope, Oedema

Question 1

Palpitations- what is it,

Answer 1

• Palpitation is an unexpected or unpleasant awareness of theheart beating in the chest.
• Detailed history taking can help to distinguish the different types of palpitation

Question 2

Palpitations- what to ask about

Answer 2

• nature of the palpitation: is the heart beat rapid, forceful or irregular? Can the patient tap it out?
• timing of symptoms: speed of onset and offset; frequency and duration of episodes
• precipitants for symptoms or relieving factors
• associated symptoms: presyncope, syncope or chest pain
• history of underlying cardiac disease.

Question 3

Palpitations- types (ectopic beats, premature ectopic beats

Answer 3

• Healthy people are occasionally aware of their heart beatingwith normal (sinus) rhythm, especially after exercise or in stressful situations
• The sensation is often more common in bed at night and some people may notice it when lying on their left side.
• Ectopic beats (extrasystoles) are a benign cause of palpitation at rest and are abolished by exercise.
• The premature ectopic beat produces a small stroke volume and an impalpable impulse due to incomplete left ventricular filling.
• The subsequent compensatory pause leads to ventricular overfilling and a forceful contraction with the next beat.
• Accordingly, patients describe missed beats

Question 4

Palpitations- SVT and VT

Answer 4

• Supraventricular tachycardia produces sudden paroxysms of rapid, regular palpitation.
• that can sometimes be terminated with vagal stimulation using Valsalva breathing manoeuvres or carotid sinus pressure.
• It often affects young patients with no other underlying cardiac disease.
• Ventricular tachycardia can produce similar symptoms but is more commonly associated with pre-syncope or syncope, and tends to affect patients with cardiomyopathy or previous myocardial infarction.

Question 5

Palpitations- High-risk features that increase the likelihood of a life-threatening arrhythmia such as ventricular tachycardia include:

Answer 5

• previous myocardial infarction or cardiac surgery
• associated syncope or severe chest pain
• family history of sudden death
• Wolff-Parkinson-White syndrome
• significant structural heart disease such as hypertrophic cardiomyopathy or aortic stenosis.

Question 6

Syncope- definition, mechanism, causes

Answer 6

• Syncope is a transient LOC
• due to transient cerebral hypoperfusion
• episodes are typically characterised by rapid onset,short duration,and spontaneous complete recovery.
• Causes include postural hypotension, neurocardiogenic syncope, arrhythmias and mechanical obstruction to cardiac output.

Question 7

Pre-syncope

Answer 7

• The same mechanisms may lead to a sensation of light-headedness and impending loss of consciousness without progressing to actual loss of consciousness (presyncope).

Question 8

Differential diagnosis of syncope

Answer 8

• The main differential diagnosis of syncope is seizure, while light-headedness and pre syncope must be distinguished from dizziness or vertigo due to non-cardiovascular causes

Question 9

Questions to ask in syncope patients

Answer 9

• circumstances of the event and any preceding symptoms: palpitation, chest pain, lightheadedness, nausea, tinnitus, sweating or visual disturbance
• duration of loss of consciousness,
• appearance of the patient while unconscious
• any injuries sustained (a detailed witness history is extremely helpful)
• time to recovery of full consciousness and normal cognition
• current driving status, including occupational driving.

Question 10

Questions to ask pre syncope patients

Answer 10

• In patients with pre syncopal symptoms of lightheadedness or dizziness, ask about:
• exact nature of symptoms and associated features such as palpitation
• precipitants for symptoms, such as postural change, pro-longed standing, intense emotion or exertion
• frequency of episodes and impact on lifestyle
• possible contributing medications, such as anti hypertensive agents

Question 11

Postural hypotension-

Answer 11

Postural hypotension, a fall of more than 20 mmHg in systolic blood pressure on standing, may lead to syncope or pre-syncope.
- It can be caused by hypovolaemia, drugs or autonomic neuropathy
- is common in the elderly, affecting up to one-third of individuals over 65 years.

Question 12

Reflex or neurogenic syncope

Answer 12

• Reflex or neurocardiogenic syncope results from excessive autonomic reflexes which produce sudden bradycardia) and/or vasodilatation.

Question 13

Vasovagal syncope- definition, Sx, how to manage

Answer 13

• Vasovagal syncope is the most common form of reflex syncope and may be triggered in healthy people following a period of prolonged standing or a painful or emotional stimulus, such as the sight of blood.
• There is typically a prodrome of light-headedness, tinnitus, nausea, sweating and facial pallor, and a darkening of vision before loss of consciousness.
• When laid flat to aid cerebral circulation the individual wakes up, often flushing from vasodilatation and nauseated or even vomiting due to vagal overactivity.
• lf the person is held upright by misguided bystanders, continued cerebral hypoperfusion delays recovery and may lead to a seizure and a mistaken diagnosis of epilepsy.

Question 14

Vasovagal- how to distinguish

Answer 14

• in patients presenting with transient loss of consciousness, predictors of vasovagal syncope include
• a history of syncope or pre syncope with pain or medical procedures,
• an age less than 35 at first syncopal episode,
• prodrome of sweating, warmth or
• abdominal discomfort
• or a postdrome of nausea.

Question 15

Hypersensitive carotid sinus syndrome

Answer 15

• In patients with hypersensitive carotid sinus syndrome, pressure over the carotid sinus may lead to reflex bradycardia and syncope

Question 16

Arrhythmias causing syncope

Answer 16

• Arrhythmias can cause syncope or pre syncope.
• The most common cause is bradyarrhythmia caused by sinoatrial disease or atrioventricular block: Stokes-Adams attacks.
• Rate-limiting drugs are a common cause of bradyarrhythmia.
• Supraventriclar tachyarrhythmias, like atrial fibrillation, rarely cause syncope
• whereas ventricular tachycardia often causes syncope or pre-syncope, especially in patients with impaired left ventricular function.

Question 17

Syncope Mechanical obstruction- LV Outflow, PE and cardiac tumours

Answer 17

• Mechanical obstruction to left ventricular outflow
• including severe aortic stenosis and hypertrophic cardiomyopathy,
• can cause syncope or presyncope, especially on exertion, when cardiac output cannot meet the increased metabolic demand.
• Massive pulmonary embolism can lead to syncope by obstructing outflow from the right ventricle; associated features are usually apparent and include acute dyspnoea, chest pain and hypoxia.
• Cardiac tumours, such as atrial myxoma, and thrombosis, or failure of prosthetic heart valves are rare causes of syncope.

Question 18

Oedema-

Answer 18

• Excess fluid in the interstitial space causes oedema (tissue swelling).
• It is usually gravity-dependent and so is seen especially around the ankles, or over the sacrum in patients lying in bed.
• Unilateral lower limb oedema may occur in deep vein thrombosis (DVT)
• Heart failure is a common cause of bilateral lower limb oedema, but other causes include chronic venous disease, vasodilating calcium channel antagonists (such as amlodipine) and hypoalbuminaemia.

Question 19

Red flags for TLOC

Answer 19

• Persistent bradycardia- requires cardiac monitoring
• Structural defects (?murmur)
• LVSD
• During exercise
• Whilst supine
• Known cardiac conditions- WPW, Brugada, Long QT syndrome
• Pathological Q waces on ECG