Lecture 15: Fainting and palpitation, Diagnostic and Treatment strategies

Question 1

What are the key issues of syncope?

Answer 1

Fainting common and usually benign
+ History is essential

Palptitation/tachycardia

• Commonly benign arrhythmias
• Exception, those with significant cardiac substrates

Question 2

What is syncope?

Answer 2

Self limited loss of consciousness and POSTURAL TONE

• Rapid onset
• Variable warning symptoms
• Spontaneous, complete, and usually prompt recovery w/o intervention

Underlying mechanism: Transient global cerebral hypoperfusion

Question 3

What are the two types of transient loss of consciousness? (TLOC)

Answer 3

Non-traumatic TLOC

• Syncope
• Epileptic seizures

Traumatic TLOC

• Psychogenic
• Rare cause

Question 4

Whats the diagnosis plan for syncope?

Answer 4

• History
• Examination
• Appropriate investigations
  + Rhythm documentation
  + Assess for structural heart disease
• Diagnosis by exclusion (rule out sig. cardiac or neurological disease)
• No cause in 1/3->1/2 of cases

Question 5

Why is patient history essential?

Answer 5

• Circumstances i.e symptoms, injuries
• Past medical history / other vents
• Family history i.e cardiac disease, sudden death, metabolic disorders

Question 6

What is the initial assessment following TLOC?

Answer 6

Vitals, CV and neuro exam

Vital signs

• HR
• Postural blood pressure change (Orthostatic)

CVS exam
- JVP (volume)
- Cardiomeagly or CHF
- Valvular disease
- Vascular brutis 
Neurological exam
- Cerebral function?
- Parkinsons

Question 7

On the inital assessment what are you looking for on ECG and echo?

Answer 7

ECG: Long QT, Pre-excitation, conduction system disease
Echo: LV function, valve status, HCM

Question 8

What are other diagnostic tests following TLOC?

Answer 8

Ambulatory ECG/monitoring

• Holter monitoring
• Event recorder

Provocative tests
- Tilt testing (Head up Tilt) (Drug induced)

Carotid sinus massage

Question 9

What are some neurologically mediated syncope causes?

Answer 9

• Vasovagal syncope
• Carotid sinus syndrome
• Situational syncope (i.e Pain, Psychological, Cough)
• Physiological i.e Cardioinhibitory, vasodepressor

Question 10

What causes postural hypotension?

Answer 10

Drug induced
- Diuretics or vasodilators
Primary autonomic failure
- Multiple systems atrophy
- Parkinsons
- Postural Orthostatic Tachycardia Syndrome (POTS)
Secondary autonomic failure
- Diabetes
- Alcohol
- Amyloid

Question 11

What are the treatment strategies for syncope?

Answer 11

• Optimal is debated but:
• Patient education, avoidance of injury
• Hydration (Fluids, salt, diet) (Minimise caffeine, alcohol)
• Support hose
• Drug therapies
• Pacing

Question 12

What is the risk of cardiac syncope?

Answer 12

• Potentially life threatening
• May be warning sign of CVD
  + Tachy and brady
  + Myocardial stenosis, aortic stenosis, aortic dissection

Question 13

Describe syncope due to bradycardia

Answer 13

• Sinus arrest
• High grade or acute complete AV block
• Can be accompanied by vasodilation (VVS,CSS)

Question 14

Describe scope due to tachycardia

Answer 14

• Atrial fibrillation/flutter with rapid ventricular rate (i.e pre-excitation syndrome)
• Paroxysmal SVT or VT

Question 15

What is the plan for syncope?

Answer 15

• HISTORY
• Examination
• some investigations
• MANAGEMENT

Question 16

What are palpitations? and treatments?

Answer 16

• Awareness of heart rate or rhythm change
• Usually transient or benign
  i. e ectopic, nocturnal/rest

= Exclude significant heart disease

Treatments = often more harmful than good

Question 17

What is the mechanism of long QT syndrome?

Answer 17

• Abnormalities of Na and/or K channels
• Susceptible to polymorphic VT

Often drug induced