TLOC / Syncope/ dizziness

Question 1

The majority of syncope episodes are neurally mediated. What does this mean?

Answer 1

Vasovagal carotid sinus situational

• cough
• micturation
• defecation
• swallow
• others

Question 2

Which cardiac arrhythmias cause syncope?

Answer 2

Brady

• sick sinus
• AV block

Tachy

• VT
• SVT

Inherited

Question 3

Non-syncopal causes of loss of consciousness

Answer 3

metabolic
epilepsy
intoxications
drop attacks
psychogenic
TIA
falls

Question 4

Minimum investigations for syncope

Answer 4

•History
–Key features: Anxiety, absence of warning, on exercise, multiple episodes, significant PMH of cardiac disease, alcohol, SOB, medication.

•Examination
–arrhythmia, CCF, postural hypotension, valvular problems

•ECG
–Rhythm, axis, qt, right heart strain

Possible investigations
•24 hour tape, implantable loop recorder.
•Tilt table test, carotid sinus massage
•EEG, brain imaging
•Exercise testing
•Echocardiogram
•CTPA
•Electrophysiological studies

Question 5

Risk factors in the history for syncope

Answer 5

• Syncope on exertion
• Family History of Sudden Death or PMH of cardiac disease.
• Recurrent episodes
• Syncope occurring when lying down
• Associated with chest pain / palpitations
• Prolonged loss of consciousness
• Lack of prodrome or warning

Question 6

How to take a lying and standing blood pressure

Answer 6

• The first BP should be taken after lying for at least five minutes.
• The second BP should be taken after standing in the first minute
• A third BP should be taken after standing for three minutes
• This recording can be repeated if the BP is still falling

Question 7

Lying and standing blood pressure: What is a positive result?

Answer 7

• A drop in systolic BP of 20mmHg or more (with or without symptoms)
• A drop to below 90mmHg on standing even if the drop is less than 20mmHg. (with or without symptoms)
• A drop in diastolic BP of 10mmHg with symptoms (although clinically much less significant than a drop in systolic BP)

Question 8

What is Brugada syndrome?

Answer 8

Patients with brigade have a pseudo-RBBB and persistent ST elevations V1-V2

Question 9

List 4 Drugs causing syncope

Answer 9

• ACE / ARB
• α blockers
• Β blockers
• Calcium channel blockers
• Diuretics
• Nitrates
• Sildenafil citrate
• Antipsychotics
• Opiates
• Tricyclic antidepressants
• Ethanol
• Bromocriptine

Question 10

Which factors favour rate control vs rhythm control of arrthymias?

Answer 10

Favours rate control

• persistent AF
• less symptomatic
• Ages > 65
• Hypertension
• No history of CHF
• Previous anti-arrhythmic drug failure
• patient preference
• high stroke risk with cardioversion

Favours rhythm control

• paroxysmal AF
• newly detected AF
• more symptomatic
• less than 65 years
• no HTN
• HF clearly exacerbated by AF
• No previous anti arrhythmic drug failure
• patient preference
• low stroke risk with cardioversion

Question 11

Medications for rate control vs rhythm control of arrthymias

Answer 11

Rate control
•Digoxin (loading)
•Β blocker
•Verapamil
•Amiodarone

Rhythm control
•Sotalol
•Flecanide
•Amiodarone
•(Propafenone, Quninidine, Dronedarone, Disopyramide, Procainamide)
•DC cardioversion
•Radiofrequency ablation

Question 12

What risk factors are considered in CHADVAS?

Answer 12

• CHF
• HTN
• Age > 75
• Diabetes
• Stroke/TIA history
• vascular disease
• age 65-74
• sex (female)