Syncope Flashcards
most common cause of syncope in young and middle aged populations
neurocardiogenic (vasovagal or vasodepressor) syncope
most common causes of syncope in elderly
LV outflow obstruction or arrhythmias
1st steps to clarify etiology of syncope
history, physical exam, medication list.
May need orthostatics, EKG, TTE, and stress test to rule out structural heart dx
PTs with unclear etiology of syncope should get:
ambulatory loop recording with holter monitor, mobile telemetry, or implantable loop recorder.
what does upright tilt testing do?
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.
initial assessment of syncope and high risk features that merit further evaluation if there is 1 or more present:
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
neurocardiogenic syncope is also known as
vasovagal syncope
neurocardiogenic syncope clinical features
: diarphoresis, nausea, generalized warmth, (signs of an autonomic prodrome)
signs suggestive of sinister etiology for syncope on physical exam:
chest pain, abnormal vital signs, abnormal physical exam or signs of injury
management of neurocardiogenic syncope
if they have clear vasovagal symptoms, they ned to have reassured if they returned to baseline and discharged as outpatient follow up.
management for sinister syncope
needs admission for telemetry if high suspicion of syncope due to cardiac arrhythmia.
Sinister syncope features on clinical history:
syncope while sitting or lying supine, exertional syncope, absence of prodrome
ECG abnormalities, prior history of CAD dx
when do we get outpatient ambulatory cardiac monitoring (holter)?
syncope is not entirely consistent with neurocardiogenic syncope but there’s a low risk for VT.
When do we get brain imaging and EEG?
not for syncope but for diagnosing seizure disorder cause.
twitching while someone passes out
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.
who gets admitted to the hospital for telemetry? (indication)
seriously ill pts who have may life threatening cardiac arrhtyhmias
ambulatory (Holter) electrocardiography (Continuous or intermittent recorders) indications
pts with frequent episodes with syncope >1 /week and can store up to 24-48 hrs of data
external loop recorder indications
syncope free interval >1 /month
implantable loop recorder indications
recurrent infrequent <1/month syncope to identifiable cause
can provide monitoring for months to years
syncope triggered by prolonged standing, emotional distress, painful stimuli and see prodromal symptoms of nausea, warmth, and diaphoresis
vasovagal or neurally mediated syncope
syncope triggered cough micturation and defecation
situational syncope
syncope with postural changes in heart rate/blood pressure after standing suddenly
orthostatic syncope
syncope after exertion or during exercise
aortic stenosis,
HCM
anomalous coronary arteries
syncope with prior history of CAD, MI, cardiomyopathy, or low EF
ventricular arrhythmias
syncope with sinus pauses, Increased PR or QRS duration
sick sinus syndrome, bradyarrhythmias, AV block
syncope with hypokalemia, hypomagnesemia, medications causing increased QT prolongation
Torsades de pointes (acquired long QT syndrome)
syncope and family history of sudden cardiac death, Increased QT interval, syncope with triggers (exercise, startle, and sleeping)
congenital long QT syndrome.
diagnosis of postural hypotension
also called orthostatic hypotension
within 2-5 minutes of standing from supine position
drop in SBP>20 or drop in DBP>10
Cardiac myxoma is a
benign neoplasm and 80% located in left atrium
clinical features of a cardiac myxoma
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
diagnosis and management of cardiac myxoma
TTE
prompt surgical resection- to avoid embolization and risk sudden death
transient vision loss (amaurosis fugax) and see unintentional weight loss and diastolic murmur
cardiac myxoma
see fatigue and mimic mitral valve dx with early diastolic sound.
carotid sinus hypersensitivity syncope
pressure on the carotid sinus by a tight collar nad neck movements while getting dressed in the AM
shaving the neck
diagnosis of carotid sinus hypersensitivity
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.
DO NOT do a carotid sinus massage and should be AVOIDED in pts who have
should avoid carotid sinus massage with ipsilateral carotid artery stenosis or carotid bruits or hx of TIA or stroke in the last three months
carotid sinus hypersensitivity treatment
permanent pacing
