SIM Case Flashcards
What should you ask in syncope history?
- Verify true transient LOC (witness?)
- Past episodes
- Context
- Comorbid illness
- Recent medicine changes
- Hx of heart DZ
- Family Hx sudden death
- Psychiatric Hx
What physical exam should you do for syncope?
- Vitals
- Orthostatic vitals
- Neuro exam
- CV exam
- Pulmonary exam
What labs/tests/procedures should you do for syncope?
- Telemetry (long QT, arrhythmia)
- Pulse-Ox
- 12-lead EKG (ischemia, conduction blocks)
- CBC, glucose (urine HCG)
- BNP ( if + –> inc. risk for cariogenic etiology)
What is the significance of BNP?
- 82% sensitivity, 92% specificity at identifying cardiac cases of syncope when BNP elevated
- Elevated BNP is important independent predictor of serious CV outcomes
What are the four types of syncope?
- Neurally (reflex) mediated
- Cardiogenic
- Autonomic dysfunction
- Other causes
What is syncope?
Transient LOC secondary to cerebral hypoperfusion characterized by rapid onset, short duration, and complete spontaneous recovery
What are the types of neurally mediated (reflex) syncopes?
- Vasovagal
- Situational
- Carotid sinus syncope
What are the types of vasovagal syncopes?
Vasovagal (fainting)
- Nonclassical
- Classical: pain, fear, emotional distress, prolonged standing
What is situational neurally mediated syncope?
Occurs during or immediately after urination, defecation, coughing, sneezing, swallowing, exercise, weight lifting, others
What is Carotid Sinus neurally mediated syncope?
Rarely due to mechanical stimulation of carotid sinus, more commonly without mechanical stimulation and diagnosed by carotid massage (glossopharyngeal neuralgia)
What are two mechanisms that cause cardiogenic syncope?
- Arrhythmias
- Structural disease
What arrhythmias can cause cardiogenic syncope?
- SA/AV node dysfunction
- PSVT
- Paroxysmal Vtach
- Medicaiton effects
- Ischemic/CAD
- Pacer/ICD dysfunction
- Inherited syndromes (Long QT)
- Brugada syndrome (inherited cardiac disease causing v-tach in structurally normal heart –ECG pattern includes RBBB and ST elevation in V1-V3)
What structural disease can cause cardiogenic syncope?
- Obstructive cardiac valve DZ
- Acute coronary syndrome
- Obstructive cardiomyopathy
- Atrial myxoma
- Acute dissection of aorta
- Pericardial disease
- Pericardial tamponade
- Pulmonary hypertension
- Pulmonary embolism
What are the categories of autonomic dysfunction?
[Orthostatic hypotension]
- Primary autonomic failure
- Secondary autonomic failure
- Other causes
What is primary autonomic failure?
Pure autonomic failure
-Lewy body disease (multiple system atrophy), Parkinson disease
What is secondary autonomic failure?
-Diabetic neuropathy, amyloid neuropathy, spinal cord injury
What are other causes of autonomic dysfunction?
- Medication = antihypertensives, diuretics (hydrochlorothiazide), TCAs, phenothiazines, ACh inhibitors
- Alcohol, Exercise, Post-prandial (after meal)
- Orthostatic hypotension from volume depletion - diarrhea, hemorrhage, vomiting
What are clues for Neurally mediated syncope?
-Defacation, urination, prolonged coughing, pain, fever, heat exposure
What are clues for cariogenic mediated syncope?
-Syncope during prone posture, during exercise, palpitations, startling (alarm clock, siren) - more likely prolonged QT syndrome
What are clues for autonomic dysfunction?
Standing quickly/prolonged standing, postprandial, heat exposure, following exercise
What is the prevalence of Syncope?
- 3-37% lifetime prevalence
- 6% annual incidence in institutionalized elderly
- 3% of ER visits
- 1% of hospital admissions
What ages most often have syncope?
Age 10-30, >65 yrs
What are the most common causes of syncope?
- Unknown (34%)
- Vasovagal (18%)
- Cardiac arrhythmia (14%)
- Neurologic (10%)
- Orthostatic (8%)
- Situational (5%)
- Cardiac structural disease (4%)
- Psychogenic (2%)
- Carotid sinus (1%)
What is Vtach?
3 or more consecutive beats of ventricular origin (wide QRS) at rate 100-200 bpm
