Syncope and HTN

Question 1

Pathophysiology of syncope

Answer 1

Reduced cerebral blood flow => syncope

*baroreceptors try to respond with autonomics to maintain brain perfusion, but fail, leading to syncope

Question 2

What may commonly mimic syncope?

Answer 2

Siezures, narcolepsy, head injury, hypoglycemia, acute intoxications

Question 3

Syncope types:

Syncope that is preceded by light headedness, dizziness, and presyncope with sudden postural change

Answer 3

Orthostatic hypotension

*syncope is preceded by warning symptoms

Question 4

Syncope types:

Syncope that occurs suddenly with few warning symptoms, often while supine or during exertion

Answer 4

Cardiac syncope

*syncope is not preceded by warning symptoms

Question 5

Risk factor assessment for syncope

Answer 5

San Fransisco Syncope Rule predicts risk of serious outcomes following episode of syncope.

• CHESS
• CHF history
• Hematocrit <30%
• ECG abnormal
• SOB
• SBP <90

Question 6

Treatment/management of neurally mediated syncope

Answer 6

Reassurance, avoidance of triggers, increase plasma volume w/ fluid and salt

Physical counterpressure maneuvers of the limbs

Question 7

Treatment/management of orthostatic hypotension

Answer 7

Remove reversible causes (most often medications)

Question 8

Treatment/management of cardiac syncope

Answer 8

Electrophysiology for pts with suspected arrhythmic etiology

Treat underlying cardiac disorder

Question 9

Risk factors for HTN

Answer 9

Modifiable: smoking, DM, lipids/cholesterol, obesity, physical inactivity, diet

Fixed: CKD, low SES, obstructive sleep apnea, psychosocial stress

Question 10

HTN type:

Elevated BP with no underlying cause

Answer 10

Primary (essential) HTN

Question 11

HTN type:

Elevated BP with a specific underlying disorder

Answer 11

Secondary HTN

Question 12

HTN type:

Severe BP elevation (>180/110) without symptoms of underlying end organ damage

Answer 12

Asymptomatic severe HTN

Question 13

HTN type:

Severe BP elevation (>180/110) with symptoms of severe end organ damage

Answer 13

Hypertensive emergency

Question 14

How to diagnose HTN

Answer 14

average >2 BP readings on >2 occasions

Question 15

Diagnostic labs/imaging for HTN

Answer 15

CBC
CMP
Lipid panel
TSH
UA
ECG

Question 16

Treatment/management of asymptomatic severe HTN

Answer 16

Lower BP gradually

*no evidence that lowering acutely and aggressively improves outcomes

Question 17

Treatment/management of hypertensive emergency

Answer 17

Lower MAP 10-20% in first hour, 5-15% over next 24 hours

*use anti-hypertensives

Question 18

HTN Treatment and management:

Pt with elevated BP (120-129/<80)

Answer 18

Non-pharmacological therapy

Question 19

HTN Treatment and management:

Stage 1 HTN (130-139/80-89)
CVD risk <10%

Answer 19

Non-pharmacological therapy, reassess in 3-6 months

Question 20

HTN Treatment and management:

Stage 1 HTN (130-139/80-89)
CVD risk >10%
*DM, CKD, older than 65

Answer 20

Non-pharmacological therapy, start BP lowering medication (ACEi, ARB, diuretic)

Question 21

HTN Treatment and management:

Stage 1 HTN (130-139/80-89)
CVD risk >10%
*DM, CKD, older than 65

Answer 21

Non-pharmacological therapy, start BP lowering medication (ACEi, ARB, diuretic)

Question 22

HTN Treatment and management:

Stage 2 HTN (>140/90)

Answer 22

Non-pharmacological therapy, start BP lowering medication (ACEi, ARB, diuretic)

*start 2 anti-HTN agents of different classes

Question 23

Goals of HTN treatment and management

Answer 23

BP <130/80

Question 24

Best treatment for HTN

Answer 24

Lifestyle modifications

• weight reduction, reduce salt in diet, DASH diet, moderate EtOH, physical activity
• DASH diet can reduce SBP by 11.2 mmHg on average