Hypotension

Question 1

1) Define syncope
2) What is the immediate cause?

Answer 1

1) Abrupt, transient complete loss consciousness associated with inability to maintain postural tone with rapid spontaneous recovery (not just MS changes such as intoxication or opioid OD)
2) Immediate cause is transient cerebral hypoperfusion
-Systemic vasodilation, decreased cardiac output, or both

Question 2

What is the MOA of syncope?

Answer 2

Usually a combination:
1) Cardiac: decreased cardiac output (CO), most often associated with sudden cardiac death
2) Reflex (neurogenic): most common type affecting systemic vascular tone and CO
3) Provoking factor: fear, pain, emotional distress, cough, micturition
4) Orthostatic: usually associated with positional changes
Dehydration, anemia, medication use

Question 3

List at least 4 DDxs for syncope

Answer 3

1) Seizure
2) Psychogenic
3) Rare: vertebrobasilar TIA, subclavian steel syndrome, cataplexy, drop attacks
4) Hypoglycemia

Question 4

Describe orthostatic measurements for syncope

Answer 4

1) Measure BP and HR 5 minutes after supine and 3 minutes after standing
2) Decrease of 20 mm Hg SBP or 10 mm Hg DBP = + test = orthostatic hypotension

Question 5

List 2 things syncope eval can include

Answer 5

1) Orthostatic measurements
2) 12 lead EKG

Question 6

Describe potential findings with a 12 lead EKG with syncope

Answer 6

1) Findings c/w ischemia
2) Mobitz type 2 and type 3 heart block
3) Persistent bradycardia
4) Sinus pause
5) Tachyarrhythmia
6) Many others

Question 7

How do you manage:
1) Cardiac related syncope
2) Reflex syncope
3) Orthostatic syncope

Answer 7

1) Treat underlying issue (decreased cardiac output)
2) Patient education (trigger avoidance) and reassurance
3) Patient ed and reassurance, anticipating triggers

Question 8

Orthostatic hypotension:
1) Define it
2) Define it numerically
3) What changes can also be seen?

Answer 8

1) Drop in BP after assuming a standing position from supine
2) Dx: drop of 20 mm Hg or more SBP or drop of 10 mm Hg or more DBP
3) Similar BP changes 60 degrees head up on tilt table

Question 9

What are orthostatic hypotension Sx (not required for Dx) due to?

Answer 9

Inadequate physiologic compensation and organ hypoperfusion

Question 10

What are the risk factors for orthostatic hypotension?

Answer 10

Prevalence increased in elderly – decreased baroreceptor sensitivity and increasd autonomic neurodegenerative disease
Peripheral neuropathy - T2DM
Postural symptoms that only occur when standing

Question 11

List the Sx of orthostatic hypotension

Answer 11

Constitutional: fatigue
CNS: HA, lightheaded, presyncope/syncope
Retina: Visual disturbance
CV: CP, palpitations, pallor, weakness
Pulmonary: dyspnea
GI: nausea
MSK: Shoulder and neck pain (coat hanger syndrome)

Question 12

What is the significance of orthostatic hypotension?

Answer 12

significant increase in CV risk, all cause mortality, and falls

Question 13

Orthostatic hypotension mgmt:
1) What are the goals? How is this done?
2) What is a common cause in young women?

Answer 13

1) Reduce symptoms, improve QOL
-ID and treat underlying conditions
2) Anemia

Question 14

List some exacerbating activities to avoid or modify for orthostatic hypotension

Answer 14

Post prandial hypotension – smaller more frequent meals
Avoid hot humid conditions which leads to cooling via vasodilation
Proper hydration