Cardio

Question 1

what do you do for vasovagal syncope?

Answer 1

leave them flat on the floor until they feel better (put pillow under head etc)

Question 2

what is syncope?

Answer 2

temporary loss of consciousness causes by a sudden fall in blood pressure causing transient global cerebral hypoperfusion

Question 3

how is syncope characterised?

Answer 3

rapid onset
short duration
spontaneous complete recovery

Question 4

most common group of causes of syncope?

Answer 4

cardiovascular causes

Question 5

esc classification of syncope?

Answer 5

reflex syncope
orthostatic syncope
cardiac syncope

Question 6

types of reflex syncope?

Answer 6

vasovagal
situational
carotid sinus syncope
atypical

Question 7

what is vasovagal syncope?

Answer 7

reflex activation causing vasodilation, bradycardia or both
syncope occurs due to decreased cerebral blood flow
get pooling of blood in peripheries

Question 8

3 Ps of vasovagal syncope?

Answer 8

posture (happens when standing or can be prevented by sitting down)
provoking factors (pain or medical procedure)
prodromal features (sweats, dizzy etc)

Question 9

risks of vasovagal syncope?

Answer 9

no risk from event itself
doesnt indicate any cardio problem
risk only comes from injury during fall

Question 10

what is situational syncope?

Answer 10

type of reflex syncope which is clearly and consistently provoked by trigger (eg having blood taken, coughing, straining, difficult swallow, post exertion etc)

Question 11

types of orthostatic syncope?

Answer 11

primary autonomic failure
secondary autonomic failure
drug induced
volume depletion

Question 12

types of orthostatic hypotension?

Answer 12

classic - drop in systolic BP 20+mmHg and diastolic 10+mmHg within 3 mins of standing
initial - immediate decrease on standing up of >400mmHg then rapidly returns to normal
delayed/progressive - common in elderly where they slowly develop hypotension and sometimes a mild bradycardia

Question 13

types of cardiac syncope?

Answer 13

bradycardia
tachycardia
tachy-brady syndrome
structural disease
other (PE, aortic dissection etc)

Question 14

types of structural problems causing syncope?

Answer 14

obstructive (aortic stenosis, hypertrophic cardiomyopathy)
pump failure
(MI, tamponade)
extra-cardiac (aortic dissection, PE)

Question 15

non-syncope causes of loss of consciousness?

Answer 15

epilepsy

Question 16

what features suggest epilepsy as cause of loss of consciousness?

Answer 16

tongue biting
head turning to one side
no memory of abnormal behaviour
unusual posturing
prolonged limb jerking
post event confusion
prodromal deja vu

Question 17

red flags in loss of consciousness?

Answer 17

abnormal ECG
heart failure
family history of sudden cardiac death
new/unexplained breathlessness
TLoC during exertion
heart murmur

Question 18

how do physiological palpitations happen?

Answer 18

taking substances which causes increases adrenergic activity or decreased vagal activity
exercise, emotion, stress etc

Question 19

reassuring features in patient with palpitations?

Answer 19

no other features
identifiable triggers (anxiety, alcohol, caffeine)
occurring at rest or at night
short lived

Question 20

concerning features in palpitations?

Answer 20

syncope
chest pain
long duration
on exertion 
patients with other heart disease
fam history
abnormal ECG

Question 21

investigations for palpitations?

Answer 21

bloods
ECG (stress testing or long term monitoring etc)
ECHO
BP

Question 22

what defines low risk palpitations which can be managed in primary care?

Answer 22

skipped beats (means ectopics)
thumping beats
short fluttering
slow pounding and normal ECG and no fam history and no structural heart disease

Question 23

mod risk palpitations which should be referred to cardiology?

Answer 23

history suggestive of recurrent tachyarrhythmia

palpitations with associated symptoms and/or abnormal ECG and/or known structural disease

Question 24

high risk palpitations which should be urgently referred to cardiology?

Answer 24

palpitations during exercise
palpitations with syncope or near syncope
high risk structural disease
fam history of inherited heart disease/SADS
high degree AV block

Question 25

what do you look for on ECG in palpitations?

Answer 25

conduction abnormalities (QT prolongation, pre-excitation)
structural abnormalities (hypertrophy, T wave changes, heart failure)

Question 26

who should be offered ambulatory monitoring?

Answer 26

all people with unexplained syncope (including those with syncope after carotid sinus massage)

Question 27

how is ambulatory monitoring done?

Answer 27

R test monitors = if TLoC several times per week
external event monitoring = if TLoC every 1-2 weeks
loop recorder = if

Question 28

what is the tilt test?

Answer 28

used if patients have a positional component to their palpitations
attempts to trigger arrhythmia, palpitations or drop in BP

Question 29

what test if palpitations come on when exrcising?

Answer 29

exercise ECG

advise patient to refrain from exercise until advise otherwise

Question 30

why is ECHO done?

Answer 30

if there are concerns of structural disease (eg previous known heart disease, abnormal ECG, presence of murmur)

Question 31

when is EEG done?

Answer 31

if you suspect seizures

can show type of seizures

Question 32

summary of palpitations investigations?

Answer 32

everyone gets 12 lead ECG
if symptoms lasting hrs then tell patient to go get ECG next time they come on
daily or frequent short lived symptoms = 24hr tape or R test
less frequent symptoms but still weekly = 7 day R test
exertional symptoms = exercise ECG
very intermittent symptoms = event monitor (ILR if red flags)
recurrent but infrequent syncope or high risk = ILR
murmur/abnormal ECG = ECHO
seizures = neurology