Miller Syncope & Htn Flashcards
What is syncope?
Transient self limited loss of consciousness due to cerebral hypoperfusion
What is Neurally mediated syncope?
- Vasovagal syncope
- Carotid sinus syndrome
- Situational
Most common type
What causes cardiac syncope?
Arrhythmias
What are the subtypes of orthostatic hypotension?
- Initial
- Classic
- Delayed
- Neurogenic
What can mimic syncope?
- Siezures
- Sleep disturbances such as cataplexy or narcolepsy
- TBI
- Metabolic disorder
- Psychogenic
What is the tri modal incidence of the first syncopal episode?
- 20 yrs
- 60 yrs
- 80 yrs old
Sharp increase after 70
What are risk factors for syncope?
- aortic stenosis
- Impaired renal function
- BBB
- Males
- Underlying chronic disorders
- A. fib
How does neural mediated syncope present?
- Orthostatic intolerance sx:
- dizzy, light headed, fatigue
- Autonomic activations:
- diaphoresis, pallor, palpitation, nausea
- Confusion rare
What does it mean to say neural mediated syncope has a prodrome?
They had symptoms before the syncopal episode
what is orthostatic hypotension?
- Reduction of 20mmHg systolic or 10mmHg disasolic w/n 3 min of standing.
what symptoms do patients have with orthostatic hypotnesion?
- light headed
- dizzy
- presyncope
- all with sudden posture changes
___ occurs suddenly with few warning symptoms.
Cardiac syncope
How do patients with cardiac syncope present?
- Palpitations
- Chest pain
- Dizzy
- OR no prodrome
What is tilt table testing potentially helpful for?
- Suspected VVS
- Suspected delayed OH
- Distinguish between convulsive syncope and epilepsy
- Establish diagnosis of psuedosyncope
Not recommended often anymore
In what senario can a patient be referred to outpatient with syncope?
- Neural mediated syncope
- Cardiac syncope BUT no serious medical condition
What senario will a patient with syncope need to be observed?
- Age >50
- hx of cardiac dz
- functioning cardiac device
- abnormal ECG
- FH sudden cardiac death
- If the symptoms don’t point to neural mediated syncope
In what senario do patients need to be admitted with syncope?
- Major cardiac arrhythmia
- Serious CV condition
- Noncardiac conditions
- severe anemia
- major trauma
- persistent abnormal vital signs
How do you manage neural mediated syncope?
- Increase central blood volume and CO
- reassure, avoid triggers, plasma volume expansion with fluids
- Teach physical counterpressure maneuvers such as crossing legs or arm tensing
How do you manage/treat syncope due to OH?
- Remove reversible causes
- Educate about staged moving
- Compression stockings and counterpressure maneuvers
- Expand intravascular volume
How do you treat cardiac syncope?
- Electrophysiology study (EPS) is helpful if you suspect cardiac syncope, but haven’t been able to record it on ECG
- bradyarrhythmia: cardiac pace
- tachyarrhythmia: ablation, drugs cardioverter defibrillator
What is the leading single contributor to all cause mortality and disability world wide?
HTN
What are the pathological consequences of hypertension in the heart?
- Structural/functional adaptations that lead to:
- LVH
- HF
- Atherosclerotic CAD and microvascular dz
- Arrhythmias
What are the pathological consequences of hypertension in the brain?
- CVA
- Impaired cognition
- HTN encephalopathy
What are the pathological consequences of hypertension in the kidney and peripheral arteries?
- Renal injury and ESRD
- PAD
What is essential (primary) HTN?
Elevated BP with no underlying disorder
What is a hypertensive emergency?
- Severe BP elevation WITH sx of end organ damage
What is Asymptomatic severe HTN (hypertensive urgency)?
q
- severe BP elevation WITHOUT sx of end organ damage
What is normal BP?
< 120/80
What is considered elevated BP?
120-129/<80
What is stage 1 htn?
130-139/80-89
What is stage 2 htn?
>140/90
In kids what is considered htn?
- Systolic BP greater than the 95th percentile for age, sex, and height
In pregnant women what is considered hypertension?
- SBP >140 or
- DBP>90
What can indicate primary htn?
- Gradual increase in BP
- Weight gain, high sodium diet, decrease exercise
- Fhx
What can indicate secondary hypertension?
- features of cushing syndrome
- Pheochromocytoma
- Polycystic kidney
- Abdominal bruit
- Precordial murmur
What labs do you want to order for primary htn?
- fasting blood glucose
- serum creatine with eGFR
- lipid panel
- CBC/CMP
- THS
- UA
- ECG
What is the treatment for someone with elevated BP?
Nonpharmacological therapy
What is the first step when you have a patient with stage 1 htn?
- Clinical ASCVD or estimated 10 yr risk CVD risk >10%
- if high risk use BP meds
- If lower than 10% use non pharmacologic therapy and reassess
What is the treatment for someone with stage 2 htn?
- Non-pharmacologial therapy
- also BP lowering medication
- two anti HTN agents of different classes
When do you reassess someone with stage 2 htn after they begin their therapy?
- 1 month
- If they are meeting BP goal reassess every 3-6 months
- If not meeting goal look at adherence to meds and/or intensify therapy
What needs to be looked at once you start a RAS inhibitor or diuretic?
- assess electrolytes and renal function 2-4 weeks after starting
?You have a patient who is 68 yo with CKD and stage 1 hypertension, what do you do?
- Start them on BP lowering medication
- because they have CKD (or diabetes) they are automatically placed into the high CVD risk category
What are the first line HTN medications>
- RAAS inhibitors
- CCB’s
- Thiazide diuretics
- African americans respond best to CCB’s or diuretics
- Whites respond best to ACE-Is or ARBS
For a patient with DM2, CHD, BPH and A. fib, what class of HTN drugs would you use?
- A. fib → CCB
- BPH → Alpha blocker
- CHD → ACE-Is or ARBs or Beta blocker
- DM2 → ACE-Is or ARBS
What are the ACE-Is?
- Benazepril
- Fosinopril
- Lisinopril
- the “pril’s”
What are examples of ARB’s?
- Candesartan
- Irbesartan
- The “artan’s”
Examples of thiazide like diuretics?
- Chlorthalidone
- Indapamide
- HCTZ
what symptoms do you see in a patient with BP >180/110
- HA
- Light headed
- Dyspnea
- Anxiety
- Epistaxis
- Palpatation
How do you treat Asymptomatic severe HTN (HTN urgency)
- Gradually lower BP and reassess in 2-4 weeks
- NO evidence that acute inpatient tx of this improves outcomes
What will you see in a patient with HTN emergency?
Look for:
- neuro sx
- visual disturbance, exudates, papilledema
- Chest discomfort, palpitation
- acute severe back pain
- dyspnea
How do you evaluate a patient with suspected HTN Emergency?
- EKG
- CXR
- UA
- Serum electrolytes and creatine
- potentially cardiac biomarkers or CT brain
