syncope2

Question 1

what is syncope?

Answer 1

The abrupt and transient loss of consciousness associated with absence of postural tone, followed by complete and usually rapid spontaneous recovery

A symptom and NOT a diagnosis

Question 2

impact

Answer 2

30% of adult population will experience syncopal episode

3% of all ED visits in US

Can lead to significant morbidity

50% of the time a specific cause is NOT identified during initial evaluation

Question 3

Important to distinguish Syncope from other causes of LOC:

Answer 3

Pre-Syncope: lightheadedness without LOC

Drop Attack: loss of posture without LOC

Seizure: Tonic-Clonic Movements that start WITH LOC (vs hypoxic myoclonus which can occur with syncope), post-ictal recovery period

hypoglycemia
hypoxia

Question 4

types of syncope

Answer 4

Vasodepressor
AKA (Vasovagal/Neurocardiogenic)
Most Common

Cardiovascular (most dangerous)

Orthostatic Hypotension

Neuro / Functional / Psychiatric -

Question 5

Vasodepressor
AKA (Vasovagal/Neurocardiogenic)
Most Common

Answer 5

decrease preload–>not enough blood to brain for short amount of time, comes back

Pain/Noxious Stimuli
Situational (micturation (oldies), cough, defecation)
Carotid Sinus Hypersensitivity (CSH)
Fear (inc. vagal tone)
Prolonged heat exposure

Arrhythmia – Tachycardia/Bradycardia
Mechanical – Aortic Stenosis, HOCM

Question 6

Orthostatic Hypotension

Answer 6

Drugs: BP meds - Vasodilators, Diuretics, Alpha blockers

Autonomic Insufficiency (Parkinsons, DM, Adrenal Insufficiency)

Hypovolemia: Dehydration, Blood loss, infection

Question 7

Neuro / Functional / Psychiatric -

Answer 7

Pseudosyncope

TIA or Vertebrobasilar Insufficiency

Question 8

most important thing in syncope..

Answer 8

hx is absolute key!!

Question 9

more vasodepressor syncope:

Answer 9

Due to excessive vagal tone
Vasovagal Hypotension: Initiated but stressful, painful situation

Situational Vasovagal Syncope: Associated with activity that may cause increase in vagal tone

• Micturation Syncope
• After Defecation
• Post Prandial

Question 10

more vasodepressor syncope: Carotid Sinus Hypersensitivity: (Common in Elderly)

Answer 10

• Sensitive Baroreceptors in Carotid body – when activated can decrease HR and drop BP = possible Syncope
• May occur with pressure on neck – tight collar, turning neck

-if massage carotid body, it “goes haywire” causing dec. HR and BP
10 second pause of sudden cardiac death!

Question 11

orthostatic syncope

Answer 11

one of the most common presentations in hospital

Common in Elderly
Essentially Pooling of blood in LE – while standing or sitting up – leading to decreased Preload = Syncope

Question 12

causes of orthostatic syncope

Answer 12

Autonomic Insufficiency : ex: DM Neuropathy (not able to “squeeze down as fast”)

Hypovolemia:

- Dehydration (Decreased thirst/ infections)
- Blood loss

Medications:

- Vasodilators (i.e. hydralizine)
- Alpha Blockers (flomax, tamsulosin) 
- Diuretics

Question 13

Orthostatic BP Measurement:

Answer 13

Measure same arm
Measure while patient laying, sitting and standing
Wait 5min between change of position

POSITIVE IF:
a drop in BP of >= 20 mmHg
or in diastolic BP of >=10 mmHg
or experiencing lightheadedness or dizziness

Question 14

Cardiogenic Syncope

Answer 14

Mechanical or Arrhythmic

not able to maintain CO

Question 15

Cardiogenic Syncope: mechanical problem

Answer 15

Valvular: (“less lanes of traffic”)
Aortic Stenosis
Pulmonic Stenosis (less common)

Structural:
HOCM
Severe Cardiomyopathy (i.e. DCM, EF 15!)
Myxoma (intracardiac tumor on septal wall obstructing mitral valve)

Question 16

Cardiogenic Syncope: arrhythmias

Answer 16

Tachycardia:
SVT
VT
VF

Bradycardia:
Sinus Brady
AV blocks
AV dissociation

Question 17

Aortic stenosis (mechanical cardiogenic syncope)

Answer 17

LV outflow tract gradient secondary to stenosis of Aortic Valve
Aortic Stenosis likely secondary to senile degeneration/ bicuspid aortic valve

CO= SV x HR

normal pressure gradient:
LV: 120/10, Aorta: 120/80, LA: 10

aortic stenosis pressure gradients:
LV: 200/25, Aorta 110/75, LA: 25

2 year mortality: 50%

*Syncope as presenting symptom Aortic Stenosis indicates Poor Prognosis: fix with sx: replace valve

Question 18

FA: Aortic stenosis

Answer 18

Crescendo-decrescendo S1S2 systolic ejection murmur.

LV&raquo_space; aortic pressure during systole. Loudest at heart base; radiates to carotids. “Pulsus parvus et tardus”—pulses are weak with a delayed peak. Can lead to

*Syncope, Angina, and Dyspnea on exertion (SAD).
Often due to age-related calcification or early-onset calcification of bicuspid aortic valve

Question 19

Hypertrophic Obstructive Cardiomyopathy

Answer 19

??

Question 20

severe sinus bradycardia EKG:

Answer 20

around 20!

Question 21

high grade 2nd degree AVB EKG:

Answer 21

dropping every other QRS complex
regular P waves

“high grade”: could be mobitz 1 or 2

Question 22

Third degree AVB EKG:

Answer 22

A-V dissociation (“marching at own beats”)

needs pacer

Question 23

SA/AV nodal dysfunction with Pauses EKG:

Answer 23

almost 9 second pauses!!

needs pacer

Question 24

arrythmias: bradycardia: consider different part of equation

Answer 24

CO=HRxSV

here the HR is low causing the decrease CO

Question 25

tachycardias

Answer 25

CO=HRxSV

with inc. HR–>EDV decreases due to dec. filling time–>dec. SV–>dec. CO–>syncope

Question 26

SVT EKG

Answer 26

narrow complex QRS

if ventricular rhythms: would have wide QRS, SUPRAventricular has narrow QRS

HR above 150, hard to tell what type of SVT, give meds to slow down to see rhythm better
@ 180 may pass out

Question 27

Vtach EKG, what to do?

Answer 27

shock ‘em

Question 28

Vfib

Answer 28

nonperfusable rhythm, shock them

Question 29

syncope dx

Answer 29

HISTORY IS KEY !!!!!!!!!!
obtain vitals
review meds
initial EKG
do othostatics
stress test

further cardiology testing if negative tests, suspicion for arrhythmias:
holter monitor
event monitor

carotid sinus massage
tilt table testing: to evaluate for vasodepressor syncope

Question 30

syncope dx: vasodepressor

Answer 30

• Usually Associated with premonitory symptoms – Nausea, Diaphoresis
  
  • Ask for activity pt was doing at the time

Question 31

syncope dx: orthostatic

Answer 31

-Ask if occurred while patient was attempting to sit up or stand

Question 32

syncope dx: cardiogenic

Answer 32

-Ask for palpitations, SOB, any prior episodes

Question 33

dx testing is driven by

Answer 33

clinical suspicion based on History

Question 34

vasodepressor syncope tx

Answer 34

Avoid situations that may cause symptoms

i.e. sit down when urinating at night

Question 35

orthostatic syncope tx

Answer 35

Avoid dehydration
Encourage oral hydration
Volume expanders – Fludricortisone
Vasoconstrictor – Midodrine

Question 36

cardiogenic syncope tx

Answer 36

bradycardia:
Adjust medications (i.e. decrease B-blocker)
Evaluate for Pacemaker placement

tachycardia:
B-blocker or CCB
EP study or ablation if needed

Mechanical:
Treatment for AS or HOCM

Question 37

cardiovascular syncope

Answer 37

Arrhythmia – Tachycardia/Bradycardia

Mechanical – Aortic Stenosis, HOCM