Syncope and Hypertension

Question 1

What is Syncope?

Answer 1

Transient, self-limited loss of consciousness due to cerebral hypoperfusion

Question 2

What are the 3 categories of Syncope?

Answer 2

1. Neurally mediated
2. Cardiac
3. Orthostatic Hypotension

Question 3

What is the tri-modal incidence of 1st episode ages for Syncope?

Answer 3

20, 60, or 80

– sharp increase after 70

Question 4

What are some Syncope mimics that are NOT true Syncope?

Answer 4

• Seizures, sleep disturbances, psych issues

- Trauma, metabolic/toxic disorders

Question 5

Transient, self limited loss of consciousness due to cerebral hypoperfusion

Answer 5

Syncope

Question 6

What are the symptoms of Neurally Mediated Syncope?

Answer 6

Dizziness, lightheadedness, fatigue, sweating, abdominal pain and nausea

Question 7

Dizziness, lightheaded, diaphoresis, nausea and abdominal pain characterizes what type of Syncope?

Answer 7

Neurally mediated

Question 8

With Neurally Mediated Syncope, describe the eyes and urinary things that can happen

Answer 8

Eyes may remain open, deviate up or move with dilated pupils

– Urinary incontinence may occur but is rare

Question 9

For Neurally Mediated Syncope, what is the followup type?

Answer 9

Outpatient

Question 10

Cardiac Syncope warning symptoms?

Answer 10

FEW or NONE

Question 11

When does Cardiac Syncope usually occur and if any symptoms are there, what would they be?

Answer 11

Occurs while supine or with exertion

– chest pain, palpitations, etc.

Question 12

For Cardiac Syncope that involves cardiac issues, what is the followup types?

Answer 12

Observation or Admission

Question 13

What defines Orthostatic Hypotension?

Answer 13

REDUCTION in:
systolic BP > 20mmHg OR
diastolic BP > 10mmHg
= WITHIN 3 minutes of standing up

Question 14

Orthostatic Hypotension episode warning symptoms?

Answer 14

YES usually preceded by them

Question 15

Orthostatic Hypotension symptoms?

Answer 15

SUDDEN POSTURAL CHANGE

–> lightheaded, dizzy, fainting, etc.

Question 16

What can suggest the diagnosis in half of Syncope patients?

Answer 16

HISTORY

Question 17

Besides history, what else is commonly to blame for Syncope (especially orthostatic hypotension)?

Answer 17

MEDS

Question 18

The physical exam for Syncope patients is usually NORMAL. What should you take a look at?

Answer 18

Vitals (Orthostatic vitals too), cardiac and neuro

Question 19

Treatment for Neurally Mediated Syncope?

Answer 19

• Reassurance, avoid triggers, increase plasma volume
• Physical counterpressure maneuvers
  ex. leg crossing, arm tensing

Question 20

Treatment for Cardiac Syncope?

Answer 20

Treat underlying disorder

Question 21

Treatment for Orthostatic Hypotension?

Answer 21

Remove reversible causes!

- Staged movements from supine to upright, compression stockings, possible drugs

Question 22

Hypertension is usually ______

Answer 22

ASYMPTOMATIC - measure it

Question 23

In what race/ethnic group is hypertension usually more severe with an earlier onset and mortality?

Answer 23

Black people

Question 24

Hypertension doubles your risk of?

Answer 24

Cardiovascular disease

Question 25

What are some modifiable risk factors for Hypertension?

Answer 25

- Elevated cholesterol | - Obesity, diabetes, smoking

Question 26

What are some relatively fixed risk factors for Hypertension?

Answer 26

- Increasing male age - Chronic Kidney disease - Obstructive sleep apnea - Stress

Question 27

On what 4 organ/systems are the pathologic consequences of Hypertension seen?

Answer 27

HEART - most common cause of death BRAIN Kidney Peripheral arteries

Question 28

Elevated blood pressure WITHOUT an underlying disorder

Answer 28

Primary (essential) hypertension

Question 29

Elevated blood pressure WITH a specific underlying disorder

Answer 29

Secondary hypertension

Question 30

In order to classify severe hypertension/emergency, the blood pressure has to be greater than or equal to?

Answer 30

180/110

Question 31

BP > 180/110 WITHOUT end organ damage symptoms

Answer 31

Asymptomatic Severe Hypertension

Question 32

BP > 180/110 WITH end organ damage symptoms

Answer 32

Hypertensive emergency

Question 33

Normal BP level

Answer 33

< 120/80

Question 34

Elevated BP level

Answer 34

120-129/<80

Question 35

Stage 1 HTN BP level

Answer 35

130-139/80-89

Question 36

Stage 2 HTN BP level

Answer 36

> 140/90

Question 37

For children, what classifies HTN?

Answer 37

Systolic BP > 95th percentile for age, ht, wt

Question 38

For pregnant women, what classifies HTN?

Answer 38

Systolic BP >140 OR | Diastolic BP > 90

Question 39

What labs should be ordered in the diagnosis of hypertension?

Answer 39

CBC, CMP, lipid panel, TSH, UA, EKG

Question 40

Normal BP treatment

Answer 40

Lifestyle modifications

Question 41

Elevated BP treatment

Answer 41

Non-pharmacologic therapy | 120-129/<80

Question 42

If a patient has Stage 1 hypertension, what should be calculated?

Answer 42

ASCVD or 10 year CVD risk > 10%?

Question 43

Treatment for Stage 1 HTN with no CVD risk?

Answer 43

Non-pharmacologic therapy

Question 44

Treatment for Stage 1 HTN with ASCVD or a 10 year CVD risk > 10%?

Answer 44

BP lowering medication

Question 45

In what 3 conditions are patients directly placed into a high risk category and started on medication for Stage 1 HTN?

Answer 45

- Age > 65 - Diabetes - Chronic Kidney Disease

Question 46

Treatment for Stage 2 HTN?

Answer 46

BP lowering medication

Question 47

Medication for HTN involves?

Answer 47

2 agents of different classes | - assess electrolytes and renal function a few weeks after starting

Question 48

What is the BP goal when treating hypertension?

Answer 48

BP < 130/80

Question 49

What lifestyle modifications can be made to alter hypertension?

Answer 49

- exercise and weight reduction - decrease alcohol and salt intake - DASH diet -- high in fruits/veggies

Question 50

Treatment for Asymptomatic Severe HTN?

Answer 50

Gradually lower BP over several days to weeks and intensify therapy every 2-4 weeks

Question 51

What are the most common manifestations of an Hypertensive Emergency?

Answer 51

Cerebral infarction and pulmonary edema | -- neuro/eye disturbances, dyspnea, chest pain

Question 52

Treatment for a Hypertensive Emergency?

Answer 52

- Lower MAP gradually in first 24 hours | - Treat organ specific manifestations

Question 53

To treat vascular manifestations of a Hypertensive Emergency, what should be done?

Answer 53

Give IV beta blocker to RAPIDLY lower bp

Question 54

To treat kidney manifestations of a Hypertensive Emergency, what should be given?

Answer 54

Fenoldapam