Syncope Flashcards
What is syncope
sudden transient LOC and postural tone with spontaneous recovery
self limited, rapid onset
spontaneous complete recovery without intervention
What are some pre-syncopal symptoms
extreme light-headed/dizzy Tunnel vision Graying out Altered consciousness Palpitations Generalized weakness Tremulousness
What are the causes of TRUE syncope
Neurally mediated (vasovagal, situational, carotid sinus syndrome) Orthostatic (drug induced, ANS failure) **Cardiac arrhythmia (brady, tachy, long QT syndrome) Structural cardio-pulmonary
What are some differentials for true syncope
**Somatization disorder (pseudo-syncope) Seizure Sleep disorder Trauma/concussion Hypoglycemia Hyperventilation POTS
What are key points to inquire about on history s/p syncopal episode
Get as many details about event (witnessed? what happened during? change in position exertion? CP? prior episodes?)
Distinguish form possible seizure
H/o cardiac disease? CVA/TIA? diabetes?
Fix of CAD? sudden death? syncope? seizures? arrhythmias?
–Cyanosis? tonic clonic? urine incontinent? tongue biting? post-octal confusion? duration?
What meds are important to inquire about
anti-HTN/depressive/anginals analgesica/narcotics muscle relaxers anti-arrhythmatics anti-ED alcohol recreational drugs
What can occur during the prodrome of a syncopal episode
uneasiness/apprehension visual blurring CP/SOB (cardiac syncope) HA/focal neuro Sx Vasovagal (light headed, facial pallor, diaphoresis, nausea)
What should you assess for on physical exam s/p syncope
pallor vs cyanosis
orthostasis (+ if 20+ drop in SBP or 10+ drop DBP 3 minutes after supine to standing)
abn rhythm, murmur, PMI, carotid brutis
MSE (assess LOC)
pupils, EOM, facial symmetry, tongue midline
imbalance/incoordination (cerebellar dysfunction)
What diagnostic studies would be good to get for syncopal suspicion
CBC, CMP, trop
ECG (holter monitor?)
Echo (if with risk factors)
Additional workup if CV abnormality or arrhythmia suspected (Echo, Holter, external loop recorder, external patch, mobile telemetry, ICD)
What extensive diagnostic tests are available depending on H&P
EP study carotid UD stress test cardiac imaging neuro test (MRI/EEG) Tilt table test
When is a Tilt table test indicated
if recurrent episodes of unexplained syncope occur
Tests for vasovagal syncope
Can help patient recognize prodromal symptoms
How do you preform a tilt table test
Lie patient down, then tilt patient upright 60-90 degrees
Abn: exaggerated drop in BP w or w/o drop in HR, associated with dizziness and light headed
What if there is a focal deficit on exam/ Normal exam
Deficit: CT +/- MRI brain, consider angio
If neuro exam is normal but neuro component suggested, refer for autonomic testing
What is vasovagal syncope
common faint, most common cause of syncope
short duration, fatigue
more common in younger patients and females
solitary attacks, no Rx needed
What are triggers for vasovagal syncope
heat exposure, prolonged standing, physical exertion
What are classic prodromal symptoms of vasovagal syncope
light headed, diaphoresis, palpitations, nausea, visual blurring/tunnel vision, diminution of hearing, pallor
What are triggers in situational syncope
micturition, cough, defecation, swallowing, emotional state, painful stimuli
What is the treatment for vasovagal syncope
avoid triggers!
education (counter pressure maneuvers, like tilt training)
If suspected ANS dysfunction, liberalize salt and water intake, compression stockings
May consider pacing
What is carotid sinus syndrome
syncope associated with carotid sinus stimulation (shaving, tight neck collar, prior head/neck surgery)
Characterized by drop in BP 50+ mmHg, or sinus pause >3 seconds
Usually older patients, VERY rare
how can you diagnose CSS
carotid massage can reproduce syncope (don’t do if with carotid bruit, prior TIA, stroke, or MI w/in 3 months)
How do you treat CSS
avoid triggers, consider pacing
What do 2017 guidelines recommend for assessing orthostatic hypotension
assess 3 minutes after standing
BUT, JAMA 2017 says 1 minute most clinically relevant
What are causes of orthostatic syncope
Hypovolemia
Meds (CCB, diuretics, vasodilators, BB)
ANS dysfunction (lesions on peripheral nerves AKA MS/parkinsons) (secondary ANS failure d/t DM, alcohol, amyloid)
How do you treat orthostatic syncope
If d/t dehydration, give fluids
If drug related, stop drug
If neurogenic, compression stocking/ Midodrine, Droxidopa, Fludrocortisone
Physical counter pressure maneuvers
Tilt training
Water intake (peak intake at 30 min)/ liberal salt intake (6-9g/d)
What should you do if orthostatic syncope continues to recur
consider pharm intervention with Midodrine or Fludrocortisone
What is cardiac arrhythmia syncope due to
Afib SVT Vtach high degree AV block Brugada
What does cardiac syncope yield
LOWER survival than other syncopes
What are bradyarrhythmias due to
Sick Sinus Syndrome (SA node dysfunction causes intermittent pause with tachy-brady syndrome) AV block (Moritz II, Complete heart block)
What are tachyarrhythmias due to
SVT WPW Afib/flutter with RVR V-Tach V-Fib Torsades (QT prolonging drugs; anti-emetics like zofran and compazine)
What are some QT prolonging drug classes
antiarrhythmics antimicrobials antidepressants antipsychotics Arsenic/Methodone
What is obstructive CV syncope due to
**Aortic stenosis (think of AS triad; syncope, hypotension, angina!)
Aortic dissection (acute “tearing pain” radiating to back. high mortality)
HCM (small LV, impaired diastolic compliance)
Pulmonary embolism
Cardiac tamponade
(also acute MI, pulm HTN)
How do you treat CV syncope
Possible pacemaker (ICD)
anti-arrhythmics
fluid (pre-load dependent conditions)
What are psychogenic causes of syncope
conversion disorder
pseudo-syncope (arm-drop test)
pseudo-seizure
How can you differentiate seizure from syncope
lateral tongue biting, head/eye turn to one side, hyper salivation suggests epileptic seizure
BUT urinary incontinence can happen with either
How can you treat pseudo syncope
assess pulse, assist to ground/chair/stretcher, avoid external dangers, attempt to arouse
Long term: treat underlying cause to prevent re-occurrence
What does the San Francisco Syncope rule identify
Low-risk its unlikely to benefit from hospital admission. IF they have any of the CHESS criteria, they are higher risk and may need hospitalization Congestive heart failure Hx Hematocrit >30% ECG abnormal (non-SR, new changes) Shortness of breath Systolic bp <90
What does the Canadian Syncope Arrhythmia risk score identify
small subset of pts that suffer arrhythmia/death w/in 30 days of ED visit for syncope Criteria include: vasovagal predisposition Hx HD ED systolic <90 or >180 elevated Trop QRS duration >130 ms QT >480 ms ED dx vasovagal syncope or cardiac syncope
How is the Canadian syncope arrhythmia risk score actually scored
For 0 points: <1% risk of arrhythmia
For 1-3 points: 1.9-7.5% risk of arrhythmia
For 4-8 points: 14.3-22.2% risk of arrhythmia
