Syncope and Autonomic Dysfunction

Question 1

syncope is A transient loss of ___ due to global ___ __

Answer 1

syncope is A transient loss of consciousness due to global cerebral hypoperfusion

Question 2

in Syncope, most people will have __ spells per life, with the first one often in ___.

Answer 2

in Syncope, most people will have 3 spells per life, with the first one often in teens.

Question 3

outcomes of acute care presentation of syncope

Answer 3

• 25% of cases had an associated cardiac morbidity.

Question 4

4 classifications of syncope

Answer 4

1. obstructive
2. arrhthmic
3. orthostatic hypotension
4. vasomotor instability

Question 5

one of the most common causes of obstructive syncope

Answer 5

1. aortic stenosis (not enough blood flow systemically including brain)
2. pulmonary emboli (also blocking blood flow)

Question 6

for bradycardia arrhthmia, ___ ___ is the most common cause

for tachycardia arrhthmia, ___ __ is the most common.

Answer 6

for bradycardia arrhthmia, COMPLETE HEART BLOCK is the most common cause

for tachycardia arrhthmia, VENTRICULAR TACHYCARDIA is the most common.

Question 7

causes of orthostatic hypotension resulting in syncope

Answer 7

1. initial orthostatic hypotension
2. volume depletion
3. hypotensive drugs
4. autonomic neuropathies

Question 8

common examples of vasomotor instability

Answer 8

vasomotor instability is a mix of hypotension and bradycardia.

• vasovagal syncope
• carotid sinus syncope
• inferior MI syncope
• situational syncope

Question 9

DDx of syncope

Answer 9

• aski, is it really syncope?

Vertigo

Dizziness

Sleep

Coma

Epileptic seizures (Convulsive activity, Tongue biting, Trauma)
Characteristic prodromes Cardiac arrest

Question 10

causes of ventricular tachycardia

Answer 10

• structural heart disease
• torsade de pointes.

Question 11

two syndromes of syncope

Answer 11

1. orthostatic hypotension
2. vasovagal syncope

Question 12

Causes of inirital orthostatic hypotension

Answer 12

Question 13

definition of classic orthostatic hypotension

Answer 13

Drop in BP >20/10 mm Hg between
supine and standing measured after 1 minute upright

Question 14

a cause of orthostatic hypotension can be due to volume depletion. What signs would show this?

Answer 14

1. poor intake, diarrhea, polyuria.
2. low JVP, skin tenting, dry mouth
3. HR rises as BP falls

Question 15

Drugs that can cause orthostatic hypotension

Answer 15

1. alpha and beta blockers that. lower BP
2. vasofilators, diuretics, nitrates (lower BP)

Question 16

a cause of orthostatic hypotension can be caused by an autnomic neuropathy. What signs would show this?

Answer 16

• associated with difficulties with sweating, urination, defecation, digestion , sex.
• primary or secondary– diabetese, autoimmune, parkinson’s MSA.
• heart rate usually incariant as BP drops (should increase if BP drops)

Question 17

treatment for orthostatic hypotension

Answer 17

 Treatment if irreversible
 Sleep with headup 15 degrees
 Support stockings
 Maximize salt and fluid if BP tolerates
 Physical counterpressure
 Florinef (fludrocortisone)
 Midodrine (amatine)

Question 18

most common cause of syncope

Answer 18

vasovagal

Question 19

outline the physiological model of vasovagal syncope that causes reflex hypotension and bradycardia

Answer 19

Question 20

note;

Question 21

diagnostic tools for syncope

Answer 21

1. careful history
2. ECG
3. Tilt Table test
4. implantable lloop recorder

Question 22

outline the chances of fainting again

Answer 22

• the more you have fainted, the more likely you are to faint again.

1 spell; 20% recurrence rate

6 syncopal spells; 60% recurence rate.

• syncope comes in clusters with gaps

Question 23

general first line measures for syncope

Answer 23

• teach patients with normal blood pressure to increase salt and fluid intake
• teach all patients to act on their prodrome with physical manoeuvres- shuffling and leg crossing, lying down, squatting, isometric leg crossing

Question 25

in addition to general treatment, what are some active treatments to consier for syncope

Answer 25

1. fludrocortisone:Intended to increase venous volume Only case report series of effectiveness Limited by hypokalemia, edema, supine HTN, headache
2. beta blockers:

• Block the effect of adrenaline
• Not effective in patients under 40

•May be effective in patients over 40

3. Midodrine: prodrug esembles norepinephrine. Increases blood pressure. Alpha1 adrenergic agonist– intended to cause venoconstriction and vasoconstriction. Helps some of the very frequent fainters. Limited by supine hypertenson, headache, piloerection.

Question 26

Non invasive treatment of vasovagal syncope:

Question 27

age range to consider using betablockers

Answer 27

use metaprolol as a non invasive treatment of vasovagal syncope in patients >40 years, especially with co-morbidities such as hypertension

Question 28

what is a conversion syndrome collapse

Answer 28

a collapse without hypotension or epilepsy. Usually young, mostly female. Physical manifestations of inner stress.

• for females; often sexual assault survivors, family abuse, pretty awful stuff.

males; often work stress, or a failed life.

Question 30

conversion syndrome collapse treatment.

Answer 30

these are the most highly distressed patients.