Syncope

Question 1

most common cause of syncope in young and middle aged populations

Answer 1

neurocardiogenic (vasovagal or vasodepressor) syncope

Question 2

most common causes of syncope in elderly

Answer 2

LV outflow obstruction or arrhythmias

Question 3

1st steps to clarify etiology of syncope

Answer 3

history, physical exam, medication list.

May need orthostatics, EKG, TTE, and stress test to rule out structural heart dx

Question 4

PTs with unclear etiology of syncope should get:

Answer 4

ambulatory loop recording with holter monitor, mobile telemetry, or implantable loop recorder.

Question 5

what does upright tilt testing do?

Answer 5

limited sensitivity and specificity for vasovagal syncope and doesn’t help guide treatment. ALso hemodynamic response during test doesn’t always reproduce the actual syncopal mechanism.

Only use for recurrent unexplained syncope when cardiac causes are enegative.

Question 6

initial assessment of syncope and high risk features that merit further evaluation if there is 1 or more present:

Answer 6

abnormal ECG (new changes)
history of structural heart dx or heart failure
systolic blood pressure <90 at triage
associated SOB during syncope
hematocrit<30%
advanced age with cardiovascular comorbities
family history of sudden cardiac death

Question 7

neurocardiogenic syncope is also known as

Answer 7

vasovagal syncope

Question 8

neurocardiogenic syncope clinical features

Answer 8

: diarphoresis, nausea, generalized warmth, (signs of an autonomic prodrome)

Question 9

signs suggestive of sinister etiology for syncope on physical exam:

Answer 9

chest pain, abnormal vital signs, abnormal physical exam or signs of injury

Question 10

management of neurocardiogenic syncope

Answer 10

if they have clear vasovagal symptoms, they ned to have reassured if they returned to baseline and discharged as outpatient follow up.

Question 11

management for sinister syncope

Answer 11

needs admission for telemetry if high suspicion of syncope due to cardiac arrhythmia.

Question 12

Sinister syncope features on clinical history:

Answer 12

syncope while sitting or lying supine, exertional syncope, absence of prodrome

ECG abnormalities, prior history of CAD dx

Question 13

when do we get outpatient ambulatory cardiac monitoring (holter)?

Answer 13

syncope is not entirely consistent with neurocardiogenic syncope but there’s a low risk for VT.

Question 14

When do we get brain imaging and EEG?

Answer 14

not for syncope but for diagnosing seizure disorder cause.

Question 15

twitching while someone passes out

Answer 15

vasovagal syncope can have brief tonic clonic movements due to transient global cerebral hypoperfusion but don’t represent a seizure disorder.

No post ictal period after syncope.

Question 16

who gets admitted to the hospital for telemetry? (indication)

Answer 16

seriously ill pts who have may life threatening cardiac arrhtyhmias

Question 17

ambulatory (Holter) electrocardiography (Continuous or intermittent recorders) indications

Answer 17

pts with frequent episodes with syncope >1 /week and can store up to 24-48 hrs of data

Question 18

external loop recorder indications

Answer 18

syncope free interval >1 /month

Question 19

implantable loop recorder indications

Answer 19

recurrent infrequent <1/month syncope to identifiable cause

can provide monitoring for months to years

Question 20

syncope triggered by prolonged standing, emotional distress, painful stimuli and see prodromal symptoms of nausea, warmth, and diaphoresis

Answer 20

vasovagal or neurally mediated syncope

Question 21

syncope triggered cough micturation and defecation

Answer 21

situational syncope

Question 22

syncope with postural changes in heart rate/blood pressure after standing suddenly

Answer 22

orthostatic syncope

Question 23

syncope after exertion or during exercise

Answer 23

aortic stenosis,
HCM
anomalous coronary arteries

Question 24

syncope with prior history of CAD, MI, cardiomyopathy, or low EF

Answer 24

ventricular arrhythmias

Question 25

syncope with sinus pauses, Increased PR or QRS duration

Answer 25

sick sinus syndrome, bradyarrhythmias, AV block

Question 26

syncope with hypokalemia, hypomagnesemia, medications causing increased QT prolongation

Answer 26

Torsades de pointes (acquired long QT syndrome)

Question 27

syncope and family history of sudden cardiac death, Increased QT interval, syncope with triggers (exercise, startle, and sleeping)

Answer 27

congenital long QT syndrome.

Question 28

diagnosis of postural hypotension

Answer 28

also called orthostatic hypotension

within 2-5 minutes of standing from supine position
drop in SBP>20 or drop in DBP>10

Question 29

Cardiac myxoma is a

Answer 29

benign neoplasm and 80% located in left atrium

Question 30

clinical features of a cardiac myxoma

Answer 30

position dependent mitral valve obstruction
see mid-diastolic murmur
dyspnea and lightheadedness and syncope

embolization of tumor fragments (stroke)

see constitutional symptoms of weight loss

Question 31

diagnosis and management of cardiac myxoma

Answer 31

TTE

prompt surgical resection- to avoid embolization and risk sudden death

Question 32

transient vision loss (amaurosis fugax) and see unintentional weight loss and diastolic murmur

Answer 32

cardiac myxoma

see fatigue and mimic mitral valve dx with early diastolic sound.

Question 33

carotid sinus hypersensitivity syncope

Answer 33

pressure on the carotid sinus by a tight collar nad neck movements while getting dressed in the AM

shaving the neck

Question 34

diagnosis of carotid sinus hypersensitivity

Answer 34

carotid sinus massage and passing out or see asystoe for 3 seconds or there’s a fall in SBP>50 mmHg

NO additional work up is needed for diagnosing.

Question 35

DO NOT do a carotid sinus massage and should be AVOIDED in pts who have

Answer 35

should avoid carotid sinus massage with ipsilateral carotid artery stenosis or carotid bruits or hx of TIA or stroke in the last three months

Question 36

carotid sinus hypersensitivity treatment

Answer 36

permanent pacing