Provocative tests: syncope and tilt testing Flashcards
Causes of syncope
-Arrhythmic
-Metabolic
-Neurogenic
-Psychogenic
-Respiratory
-Trauma
Why do you pass out from tachyarrhythmia?
-Decreased filling time (shorter diastole)
-Decreased emptying (shorter systole)
Transient loss of consciousness definition?
A state of real or apparent loss of consciousness with:
-loss of awareness, characterised by amnesia for the period of unconsciousness
-abnormal motor control
-loss of responsiveness
-a short duration
Syncope definition
Transient loss of consciousness due to cerebral hypoperfusion characterised by:
-a rapid onset
-short duration
-spontaneous complete recovery
Causes of syncope
Main cause is reflexes:
-Vasovagal
-Situational syncope
-Carotid sinus syndrome
-Orthostatic hypotension (OH)
-Cardiac syncope
Assessments for syncope?
Vital signs:
-Lying and standing blood pressure
-Blood glucose level
-Cardiac and neurological examination
-12 lead ECG
-blood test
-24 hr blood pressure/ecg
-echo
Questions to ask patient/first hand witness after syncope?
-Posture beforehand?
-Prodromal symptoms?
-Tongue biting?
-Loss of bladder/bowel control?
-Confusion afterwards?
-Family history of cardiac disease/SCD?
What warrants specialist referral? (syncope clinic/cardiologist)
-Diagnostic uncertainty
-Unexplained syncope
-Vasovagal syncope during high risk activity/affecting QoL
-Reflex syncope with absent/short prodrome
-Suspected but unconfirmed orthostatic hypotension
-Persistent orthostatic hypotension despite lifestyle modification
NICE guidelines for syncope
-Examination
-History
-12 lead ECG
-Blood tests
-24hr BP monitor
-Echo
-Video of event
Indications for Tilt test
-Clinical history suggestive of vasovagal syncope/reflex syncope
-Orthostatic intolerance
-Suspected autonomic dysfunction
-Risk stratification
Contraindications to Tilt test
Absolute:
-Inability to stand/weight bear
Relative:
-Recent stroke
-Airway support
-History of catastrophic tachyarrhythmia
-Aortic/mainstem stenosis
Clinical questions in Tilt testing
-Can syncope be reproduced by Tilt testing?
-Are symptoms reproduced in study consistent with clinical history?
-What were the haemodynamic findings?
Clinical history of Tilt testing
3 P’s
-posture
-prodrome
-provocational factors
Prodromes in Tilt testing
-Nausea/vomiting
-Diaphoresis/skin tone
-Altered vision/hearing
-Incontinence
-Witness observations
-Chest pain
-Palpitations
Provocational factors of syncope
-Exercise - during or immediately after
-Eating/alcohol consumption
-Crowded room/hot environment
-Public speaking/situational
-Micturition
-Coughing
-Menstruation
What monitoring should all Tilt tests have?
-Continuous measurement of heart rate and blood pressure
What is the Italian protocol?
-5 minutes supine
-20 minutes passive tilt at 60-70 degrees
-400mcg of GTN
-Further 15 minutes of Tilt
Non-provocational testing
-5 minutes supine
-45 minutes tilt at 60-70 degrees
What are the outcomes of a Tilt test?
-Negative/normal test
-Syncope/presyncope with vasovagal response
-Syncope/presyncope with orthostatic hypotension response
-Symptoms reproduced with haemodynamic features of postural orthostatic tachycardia syndrome (POTS)
How does GTN affect heart rate?
-Increases HR
-Contraindicated in asthma patients
What Tilt test is this?
-Orthostatic hypotension
-HR goes up
-BP goes down
What Tilt test is this?
Vasovagal
What Tilt test is this?
POTS
-Heart rate rapidly increases
What is included in Tilt report?
Haemodynamic trends:
-maximum/minimum values
-correlation with reported symptoms
Symptoms reproduced
-Consistent with clinical history?
