Syncope

Question 1

Syncope

Answer 1

• Transient, sefl-limited loss of consciousness due to acute global impairment of cerebral blood flow for 6-8 seconds
• Rapid, brief, spontaneous recovery

(aka: “passing out”, “falling out”, “fainting”, “blackout”)

Question 2

Syncope: high risk features

Answer 2

1. History of chest pain or EKG shows ischemia
2. Heart: failure, structural defect
3. Long QT
4. interventricular conduction delay
5. family Hx: sudden death
6. palpitations in time of syncopal event
7. syncope during exercise or at rest

Question 3

Syncope prevalence and cost

Answer 3

3% ER visits (1% of all hospital admissions)

35% lifetime

MC between 10-30 yrs & after 70

Question 4

Vascular causes of syncope

Answer 4

1. Cardiogenic
2. CVA
3. Volume depletion

Question 5

Infectious causes of syncope

Answer 5

• Shock
• Sepsis
• Meningitis

Question 6

Psychogenic cause of syncope

Answer 6

1. Fair
2. Disgust

Question 7

Three most common causes of syncope

Answer 7

1. Neurologic
2. Orthostatic
3. Cardiac

Question 8

Define neurologic syncope

Answer 8

Related to pathological changes to happen within the autonomic nervous system → signal medulla to decreases blood pressure and heart rate → decrease in cerebral blood flow to brain

(relies on intact ANS)

Question 9

MC causes of neurally mediated syncope

Answer 9

1. Vasovagal (MC)
2. Pulmonary (cough, wind-instrument player, the “fainting game”)
3. Urogenital (micturition syncope)
4. GI (swallow syncope, defication)
5. Cardiac (outflow obstruction)
6. Carotid sinus sensitivity
7. Ocular (sudden IOP increase)

Question 10

Orthostatic-mediated syncope is due to the body’s inability to ______

Answer 10

maintain blood pressure after standing or sitting up (HR doesn’t increase despite hypotension)

Question 11

Orthostatic hypotension is a reduction and systolic blood pressure of at least ____ mm Hg or diastolic blood pressure of at least ____ mm Hg w/in 30 minutes of standing or head tilt on a tilt table.

Answer 11

20

10

Question 12

Types of orthostatic-mediated syncope (4)

Answer 12

1. Autonomic failure (primary or secondary)
2. Postprandial hypotension
3. Drug (Iatrogenic)
4. Volume Depletion

Question 13

Peripheral neuropathies that can cause Secondary autonomic failure → orthostatic mediated syncope (5)

Answer 13

1. Amyloidosis
2. Diabetes
3. HIV neuropathy
4. Sjogren’s
5. Paraneoplastic autonomic neuropathy

(There are also hereditary sensory and autonomic neuropathies)

Question 14

Primary autonomic failure (orthostatic mediated syncope) is due to _______ (2 conditions).

Answer 14

• Lewy Body Disease
• Multiple system atrophy

Question 15

Medications for orthostatic-mediated syncope (4)

Answer 15

1. Fludrocortisone
2. midodrine
3. dihydroxyphyenlserine
4. pseudoephedrine

(2nd line: Pyridostigmine, vohmbine, desmopressin, erythropoietin)

Question 16

Cardiac-mediated syncope is due to ______ or ______ issue that prevents blood from perfusing the brain.

Answer 16

• structural
• electrical

(all are high risk!!)

Question 17

Cardiac syncope: arrhythmias causes (4)

Answer 17

1. Sinus node dysfunction
2. AV node dysfunction
3. Supraventricular tachycardia
4. Inherited channelopathy

Question 18

Cardiac-mediated syncope: structural causes (4)

Answer 18

1. Valve disease
2. Obstructive cardiomyopathies
3. Atrial Myxoma (tumor)
4. Pericardial effusions or tamponade

(obstruction or its being squeezed)

Question 19

How do you evaluate a patient for cardiac syncope (6)?

Answer 19

1. Hx of arrhythmia
2. Hx of palpitations or chest pain w/syncope
3. Known structural heart disease
4. Rx review
5. EKG
6. Echo

Question 20

It takes a ventricular heart rate above ____ or below ____ to cause syncope

Answer 20

• 200
• 40

Question 21

You must differentiate syncope from _____.

Answer 21

seizure

(patients will confuse these, key difference = time to recovery)

Question 22

Neurally-mediated syncope is due to ________ autonomic activation/autonomic failure. Orthostatic syncope is due to ________ (autonomic activation/autonomic failure).

Answer 22

• Neurally: autonomic activation
• Orthostatic: autonomic failure

Question 23

If a patient has a family history of syncope, they are at risk of developing ______-mediated syncope.

Answer 23

neurally

Question 24

What is the biggest difference between seizure and neurally-mediated syncope?

Answer 24

confusion quickly resolves after neurally-mediated syncope episode

Question 25

Symptoms during a neurally-mediated syncope event (5).

Answer 25

1. myoclonic movement/jerks 2. eyes open & deviate upward 3. dilated pupils 4. roving eyes 5. urinary incontinence

Question 26

Myoclonic movements/jerks are seen in both neurally-mediated syncope and seizures. What is the distinction?

Answer 26

* neurally-mediated: **arrhythmic & multifocal** * seizures: **rhythmic & focal**

Question 27

Autonomic symptoms seen in neurally-mediated syncope (6).

Answer 27

1. diaphoresis 2. hyperventilation 3. nausea 4. pallor 5. palpitations 6. yawning

Question 28

Coat-hanger headache is seen in \_\_\_\_\_\_-mediated syncope.

Answer 28

orthostatic

Question 29

Supine hypertension is commonly seen in \_\_\_\_\_\_-mediated syncope.

Answer 29

orthostatic (50% of patients w/autonomic failure)

Question 30

Visual blurring or blacking out is commonly seen in \_\_\_\_\_\_-mediated syncope.

Answer 30

orthostatic

Question 31

define pre-syncope

Answer 31

light-headedness/dizziness (usually response to position change that precedes orthostatic-mediated syncope)

Question 32

Medications for cardiac-mediated syncope (2)

Answer 32

1. beta blocker 2. anti-arhythmics

Question 33

What are the general differences in syncope management (between orthostatic, cardiac and neural)?

Answer 33

* Orthostatic: behavior & underlying disease * Cardiac: surgery & meds * Neural: hydration & maneuvers

Question 34

Behavioral modifications to treat ortho-static mediated syncope (4)

Answer 34

1. salt diet 2. teach them to get up slowly 3. elevate head of bed 4. control underlying disease (also medication)

Question 35

Isometric counter-pressure is used to treat \_\_\_\_\_\_-mediated syncope and vagal maneuvers are used to treat \_\_\_\_\_\_-mediated syncope.

Answer 35

* neurally * cardiac

Question 36

Other than medication, what is the treatment for neurally-mediated syncope (3)?

Answer 36

1. isometric counter-pressure (knees to chest) 2. crossed legs, flexed arms 3. IV hydration

Question 37

What are the procedures used to treat cardiac-mediated syncope (4)?

Answer 37

1. cardioversion 2. valve replacement 3. ablation 4. pacemaker implantation