CC Jan 2016 Syncope

echoecho's version from 2016-02-01 13:19


Question Answer
Define syncope?a transient loss of consciousness with complete return to baseline neurological status after the event
The majority of patients who suffer an episode of syncope have their first occurrence prior to the age of ____ years, but the incidence of syncope increases with increasing age?30
*** It is estimated that as many as 40% of patients with syncope do not seek medical attention, but when they do, more patients see their primary physician than seek treatment where?ER
True or false? Despite extensive evaluations, the cause of the syncope is unknown in between 1/4 and 1/2 of all patients?true
List the 4 categories of syncope?1) neurally-mediated 2) cardiac 3) neurogenic 4) orthostatic
Question Answer
Which of the 4 categories is the most common? Accounts for what part of all cases?neurally-mediated; 1/4 of all cases
Neurally-mediated syncope is characterized by what?an inappropriate neural reflex that resuljts in an inappropriate drop in BP and cerebral perfusion, resulting in a protective reflex of syncope
List the specific causes of neurally-mediated syncope?1) carotid sinus hypersensitivity (often precipitated by pressure on the carotid sinus by a tight collar or head turning) 2) situational (micturition, postexercise, postprandial, cough or visual mediated) 3) vasovagal (mediated by stress, lack of sleep and dehydration and preceded by nausea, dizziness and subjective flushing)
Question Answer
Cardiac syncope may be due to what?an arrhythmia or structural heart disease
Do patients with arrhythmias (severe bradycardia, ventricular arrhythmias, supraventricular arrhythmias or long QT syndrome) often have any prodrome prior to the syncopal episodeno
List the structural lesions that may be associated with syncope?1) hypertrophic obstructive cardiomyopathy 2) severe aortic stenosis 3) severe pulmonary stenosis 4) acute myocardial infarction 5) acute pulmonary embolism
Patients with structural heart disease may complain of what?palpitations, chest pain or dyspnea prior to syncope
True or false? Cardiac syncope is the least common cause of syncope?false, it is the second most common cause of syncope
Cardiac syncope is associated with a greater risk of what?cardiovascular morbidity and mortality when compared to other types of syncope
Question Answer
Neurogenic syncope is a relatively uncommon cause of syncope. List conditions that may lead to this syncope?1) steal syndrome (when exercise preferentially diverts blood from the cerebral vascular to an exercising muscle group) 2) psychogenic (panic disorder and somatization disorder)
Are syncope from TIA and CVA rare?yes
How to distinguish seizures from neurogenic syncope?in seizures there may be loss of bowel and bladder control and a postictal state of confusion and slow return to full consciousness
Question Answer
Define?when the BP fails to respond to a change in height (standing up quickly)
Orthostatic syncope is often secondary to another condition, list these?1) dehydration due to GI losses 2) poor oral intake 3) bleeding
Comment on drugs that may be associated with orthostatic syncope?1) alcohol 2) insulin 3) oral hypoglycemic 4) antihypertensives 5) antianginals 6) antidepressants 7) anti-Parkinson's therapy
List the medical conditions associated with orthostatic syncope?1) DM 2) Parkinson's disease 3) amyloidosis 4) spinal cord injury
*** Multiple strategies have been evaluated to stratify patients as high risk for cardiovascular morbidity and mortality requiring inpatient evaluation and observation or lower risk for which outpatient workup is appropriate. One clinical decision rule is the Risk Stratification of Syncope in the ER (ROSE), which foundto have a 87% sensitivity and a 98% negative predictive value for serious outcomes within 1 month of syncopal episode when it was studied in 550 adults presenting to an ER. Patients are considered high risk and should be admitted if any of the 7 criteria are present, list these 7? 1) brain natriuretic peptide > 300 pg/mL 2) bradycardia < 50 beats per minute 3) rectal exam positive for fecal occult blood 4) hgb < 9 g/dL 5) chest pain associated with syncope 6) Q waves on EKG 7) oxygen saturation < 94% on room air
What is the cornerstone to the dx of syncope (whether inpatient or outpatient)?careful hx and physical
Particular attention should be given to what regarding syncope?1) circumstances around the episode (including questioning the witnesses) 2) the condition of the pt immediately after the episode 3) a detailed med hx 4) patient's cardiovascular and neurological hx
What are the criteria to look for if orthostasis is suspected?1) drop in SBP > 20 OR 2) SBP < 90 mm Hg AFTER the patient has been standing for 1-3 minutes.
*** What procedure should be done on all patient with syncope?12 lead EKG
Limited lab studies should include what tests?1) CBC (r/o anemia) 2) BNP (when heart failure is present or suspected) 3) pregnancy test (childbearing age) 4) other studies done based upon clinical presentation
What patient type should have an echocardiogram?1) patients with unknown etiology of syncope after the initial evaluation 2) patients with a positive cardiac hx 3) for those with an abnormal EKG
When is extended EKG monitoring considered?for pts who are at high risk for an arrhythmia based upon the hx and physical exam
When is graded exercise testing used?1) for evaluation patients at intermediate risk of cardiovascular disease when the cause of syncope is unknown 2) if syncope occurs postexercise 3) if patients are at risk fo cardiovascular disease based on the presentation of risk factors
When is tilt-talbe testing used?to confirm neutrally-mediated syncope in patients with no structural heart disease or ischemia
When is electrophysiology studies recommended?1) for patients with CAD 2) patients with impaired ventricular function (LVF < 35%) 3) dilated non-ischemic cardiomyopathy
List 4 general measure to reduce the risk of recurrent syncope?1) adequate sleep 2) avoidance of triggers (cessation of causative meds if possible) 3) adequate fluid intake 4) treatment of underlying disease processes that may have caused the syncope
List simple measures to reduce the risk of recurrent syncope?1) sitting during micturition 2) arising slowly while holding onto a chair or table for a few minutes
Specific etiologies should prompt what?referral to and co-management with appropriate subspecialists.
*** SUMMARY = Despite extensive evaluations, the cause of syncope is _______ in between 1/4 to 1/2 of all patients?unknown
*** SUMMARY = Etiology of syncope may be what 4 body system causes?1) cardiac 2) neurogenic 3) neutrally-mediated 4) orthostatic
*** SUMMARY = The decision whether to observe in the hospital or do an outpatient evaluation depends on what?risk stratification