CCS Syncope and POTS/OH 2020

Question 1

5 things on history to signify high risk?

Answer 1

-Syncope during exertion or supine or without prodrome

-Symptoms suggestive of Cardiac Disease

-History of CV disease

-Family history of SCD < 50 yo

-Concomitant trauma

Question 2

4 non history features of high risk syncope?

Answer 2

-Abnormal vitals

-Abnormal cardiac exam

-Elevated cardiac biomarkers

-Abnormal ECG (any bradyarrythmia, any tachyarrhythmia, or conduction disease)

Question 3

When should neuroimaging (CT) be used?

Answer 3

Only for patients where intracranial disease is highly suspected or if there has been head trauma

Question 4

What are two pharmacotherapy for recurrent VVS? and doses?

Answer 4

-Fludrocortisone: 0.2mg/day

-Midodrine 5-15mg q4h

Question 5

When to implant PPM for recurrent VVS with cardioinhibitory response?

Answer 5

• > 3s if symptoms,
• > 6s with no symptoms
• Tilt-induced asystole > 3s or HR < 40 bpm

Question 6

4 conservative therapies for orthostatic hypotension?

Answer 6

-Education and reassurance

-Salt and water intake

-Removal of offending medications

-Counter-pressure manoeuvres, compression garments, head-up tilt sleeping

Question 7

What is driving restriction with unexplained syncope or frequent VVS or limited prodrome?

Answer 7

1 month is reasonable (weak)

For single VVS there is no driving restriction

Question 8

What is hemodynamic criteria for POTS? Clinical?

Answer 8

-Increase in HR > 30 bpm from supine to upright within 10 minutes in the absence of orthostatic hypotension

• > 40 in < 18 yo

-Clinical: Orthostatic intolerance symptoms: Light headedness, palpitations, tremulousness, atypical chest pain

For 3 months or longer

Question 9

What is PoTS +

Answer 9

POTS + one extra symptoms (Gastric emtpying, vomiting, constipation, neurogenic bladder, severe chronic pain, flushing)

Question 10

What is PSWT?

Answer 10

Postural symptoms without tachycardia

Question 11

What is PTOC? What are 5 causes?

Answer 11

Postural Tachycardia of Other cause

-Hypovolemia
-Anemia
-Anxiety and panic attacks
-Endocrinopathy
-Prolonged or sustained bed rest

Question 12

What are the 4 pathophysiological subtypes of POTS?

Answer 12

-Hyperadrenergic (Plasma levels > 600 pg/ml, SBP > 10mmg)

-Hypovolemia (Decrease 24 hour urine sodium excretion)

-Peripheral Autonomic Denervation (Restricted autonomic neuropathy of small and distal autonomic fibres, Sympathetic tone impairment, Reduce vasoconstriction, Compensatory tachycardia)

-Deconditioning: Reduced left ventricular mass, stroke volume and blood volume

Question 13

Review other autonomic symptoms

Answer 13

Question 14

What are blood work that you should order when investigating POTS?

Answer 14

-CBC
-Lytes
-Renal function
-Ferritin
-TSH
-AM Cortisol

Question 15

If diagnosis is not clear after initial blood work and physical exam -> review next steps

Answer 15

Question 16

When to do autonomic testing? (Tilt table, Catecholamine determination, Sweat test, Valsalva manoeuvre, 24 hour urine sodium, blood volume measurement)

Answer 16

When initial work up (physical, labs) is negative but there is suspicion of autonomic testing

Question 17

5 conservative management of POTS?

Answer 17

-Withdrawal of culprits

-Hydration: 3-4L/day

-Salt: 10g/2 TSPS

-Exercise and Counter pressure

-Compression garments

Question 18

What is the pharmacotherapy for POTS depending on predominant symptoms?

Answer 18

-Tachycardia: Propranolol, Ivabradine

-Low BP: Midodrine

-Hypovolemia: Fludrocortisone

-Hyperadrenergic: Methyldope, Clonidine

Question 19

What are high risk ECG features?

Answer 19

-Sinus node dysfunction ( < 50bpm, sinus pause > 3s)

-Bifascicular block, 2nd or 3rd degree heart block

-Ventricular pre-excitation

-SVT

-Afib

-Evidence of Ischemia

-Long QT, Brugada, ARVC

Question 20

Review risk stratification algorithm in syncope

Answer 20