Palpitations and Syncope Flashcards
What is Syncope?
- Loss of consciousness and postural tone
- Rapid onset
- Variable warning symptoms
- Spontaneous/complete/usually prompt recovery without intervention
Causes of Syncope
- The VAST MAJORITY of causes (of palpitations/tachycardia) are usually BENIGN rather then malignants
- Neurally-mediated reflex syndrome
- orthostatic hypotension
- cardiac arrhythmias
- Structural cardiovascular disease
Whats the impact of Syncope
40% people will experiance once in their life
1-6% hospital admissions
1% emergency room events
10% elderly fall
6% results in major morbidity
minor injury in 29%
Sufferers are sometimes not able to drive»_space; lifestyle and environmental impact
Most syncope involves a complex of something going on with the
HEART the BRAIN and the AUTONOMIC NS
**remember there are many autonomic modifiers that affect the heart, which can result in syncope
Age dispersion of Syncope
Cluster during the teenage years, decreases in middle age and then begins to strongly increase with age again.
Disorders that mimick syncope
- With loss of consciousness ie; seizure disorders, concussion
- without loss of consciousness ie; psychogenuc “pseudo-syncope’
What should your diagnostic plan for dealing with the patient be
most important?**
1) History*******
2) Examination
3) Appropriate Investigations: Rhythm documentation, assess for structural heart disease.
4) Diagnosis by exclusion: rule out any significant cardiac or neurological disease
**No cause is found in ~35-50% patients
Patient history is ESSENTIAL!
Circumstances of recent event
- eyewitnesses
- symptoms at onset
Previous events
Past medical history (what else is going on)
- cardiac
- neurological
- medication/drug history
Pertinent family history
-cardiac disease, sudden death, metabolic disorders
Types of tests we do to try find out cause
ECG, more prolonged monitering.
Provovatie tests: to try provoke hypotension or tachycardia.
Neurological Tests: ONLY do if you think there could be a seizure issue/neurological cause. Has a very low yield.
Only the history and physical examination has a high yield.
Neurally-Mediated Syncoope
- Vasovagal Syncope (VVS)
- Carotid Sinus Syndrome (CSS)
-Situational Synchope:
> post-micturition; cough etc
> pain/psychological etc
- Physiologic Reflex Mechanism
- Cardioinhibitory (HR)
- Vaso depressor
Whats seen on an ECG with a recurrent NM syncope
Sudden stopping of heat beats, no cardiac activity.
Drifting due to the patients starting to breathe in a funny fashion, bc there’s no blood going around to maintain cerebral perfusion. if it carries on > ‘aginal breathing’
Orthostatic Hypotension
Drug-induced (very common)
- diuretics
- vasodilators
Primary Autonomic failure
- multiple system atrophy
- parkinsion’s disease
- Postural orthostatic tachycardia syndrome (POTS)
Secondary Autonomic Failure
- Diabetes
- Alcohol
- Amyloid
What do all these different causes mean in terms of treatment?
That we have to be very careful and tailor treatment to the individual patient. Drug strategies and interventions are at the bottom of the list, and most of the management of syncope is ruling out any major causes and reassuring the patient.
Teaching the patient about situations to avoid, movements they can do, hydration etc
Cardiac Syncope
- Potentially life-threatening
- May be warning of significant CV disease
- Initiate assessment/treatment promptly
Types of Syncopes due to cardiac arrhythmias
Bradyarrhythmias
- sinus arrest
- High grade or acute complete AV block
- can be accomponied by vasodilation (VVS, CSS)
Tachyarrhythmias
- atrial fibrillation/flutter with rapid ventricular rate
- Paroxysmal SVT or VT
- Torsade de pointes
Very small %of these issues are actually discovered
Palpitation
- Awareness of heart rate or rhythm change
- Usually transient and benign: simple ectopic beats, often nocturnal or noted during rest, exertional less common
-malignant potential small
Palpitation and tachycardia symptoms
Symptom - history is key
Physical examination - exclusion
Differential diagnosis
Investigation
Management
-Exclude SHD/risk stratify
-Reassurance
-Treatment :
>may cause more harm then good!!
> side effects/pro-arrhythmias
>Beta blockade vs Class I agents
Examples of palpitation/tachycardia
Incessant ectopy: may reflect underlying cardiac issue
SVTs: almost ALWAYS benign, curable
ECTOPY in presense of SHD: trigger for malignant arrhythmias
CASE 1 20yr old Blackouts since teenager ED after LOC at party no other history Now recovering
History:
-no drugs/alcohol of significance, not exercising, not unwell, no family history
Echo - MVP, mild MR, PFO
Examination: is she hypotensive? Needle tracts? Diarrhoea, URT infection?
Treatment: Reassurence, Vit E/Primrose oil, review.
But then she collapsed again, turns out she had a malignant event.
Long QT Syndromes
Mechanism:
- abnormalities of Na+ and/or K+ channels
- SUsceptability to polymorphic VT
Prevalence:
- Drug-induced (common)
- Genetic (~rare)
- “concealed” forms (may be common)
Think about the medications you could use.
CASE 2:
Atrial fibrillation;
Abnormal, irregular ECG, delta waves
24years old
Accessory pathway WOWW syndrome.
At a small risk of sudden cardiac death.
CASE 3: 75 years Recurrent dizziness when standing Blackout? Witness history
Left bundle branch block. QRS completely disassociated from P wave
“Complete heart block”
Can definitely cause collapse
Needs pacemaker treatment.
