SIM

Question 1

Epidemiology of syncope

Answer 1

• 3-37% lifetime prevalence
• 6% annual incidence in institutionalized elderly
• 3% of ER visits
• 1 % of hospital admissions

Question 2

V tach

Answer 2

• three or more consecutive beats of WIDE QRS ventricular origin at 100-200 bpm
• stable = asymptomatic
• unstable = symtpoms

Question 3

Distinguish between neurally (reflex) mediated, cardiac, orthostatic, other causes

Answer 3

l

Question 4

Neurally (reflex) mediated syncope

Answer 4

• vasovagal (pain, fear, emotional distress, prolonged standing) 18% prevalence
• situational (urination, defecation, coughing, sneezing, swallowing, exercise, weight lifting, etc.) 5% prevalence
• carotid sinus syncope (shaving, massage, etc.) 1% prevalence

Question 5

Cardiac syncope

Answer 5

1. Arrhythmias (14% prevalence)
   - SA/AV node dysfunction
   - PSVT
   - paroxysmal v tach
   - ischemia/CAD
   - medication effects
   - pacer/ICD dysfunction
   - inherited syndromes (long QT, etc.)
2. Structural Disease (4% prevalence)
   - obstructive cardiac valve disease
   - ACS
   - obstructive cardiomyopathy
   - atrial myxoma
   - acute dissection of aorta
   - pericardial disease
   - pericardial tamponade
   - pulmonary HTN
   - PE

Question 6

Orthostatic syncope

Answer 6

diarrhea, hemorrhage, vomiting, adrenocortical insufficiency

8% prevalence

Question 7

Other causes of syncope

Answer 7

34% prevalence (of unknown cause of syncope)

Question 8

Management of stable v tach

Answer 8

l

Question 9

Management of unstable v tach

Answer 9

l

Question 10

Labs for syncope

Answer 10

• telemetry (long qt, arrhythmia)
• pulse-oximetry
• 12 lead EKG
• CBC
• glucose
• urine HCG
• BNP

Question 11

Definition of syncope

Answer 11

transient loss of consciousness 2* to cerebral hypoperfusion

characterized by:

• rapid onset
• short duration
• complete spontaneous recovery

Question 12

Autonomic Dysfunction

Answer 12

• 1* autonomic failure (Lewy body disease, Parkinson disease)
• 2* autonomic failure (diabetic neuropathy, amyloid neuropathy, spinal cord injury)
• medications (antihypertensives, diuretics eg. HCTZ, TCAs, phenothiazines, etc.)
• alcohol
• exercise
• post-prandial

Question 13

neurally mediated etiology clues

Answer 13

defecation
urination
prolonged coughing
pain
fear
heat exposure

Question 14

cardiogenic etiology clues

Answer 14

syncope during prone posture
during exercise
palpitations
startling
more likely prolonged QT syndrome

Question 15

autonomic dysfunction etiology clues

Answer 15

standing quickly
prolonged standing
postprandial
heat exposure
following cessation of exercise

Question 16

Syncope distribution by peak incidence

Answer 16

bimodal

• age 10-30
• age > 65

Question 17

Symptoms of unstable vtach

Answer 17

chest pain
dyspnea
hypotension (SBP

Question 18

Causes of vtach

Answer 18

CAD
cardiomyopathy
electrolytic abnormality
myocardial ischemia
hypoxemia
acidosis
idopathic

Question 19

Tx of unstable vtach

Answer 19

• immediate synchronized cardioversion (50 joules initially, repeat at increased energy levels 100, 200, 360 as necessary)

Question 20

Tx of stable vtach

Answer 20

• amiodarone

- plan for elective synchronized cardioversion

Question 21

vtach long-term Tx

Answer 21

*DC cardioversion is safest and most effective

• implantable cardioverter-defibrillator (ICD)
• amiodarone
• beta blockers

Question 22

AHA guidelines for driving after arrhythmia

Answer 22

6 months arrhythmia-free interval before driving