Met 2: Cardio; Lec. 16 Syncope, Ventricular Arrythmia And Cardiac Rhythm Device

Front 1

What is the most common cause of syncope in young adults?

Back 1

Vasovagal syncope
(neurogenic)

Front 2

What are four non-syncopal causes of loss of consciousness?

Back 2

1) Falls
2) Psychogenic ""pseudo-syncope""
3) Seizures
4) Hypoglycemia
5) Intoxication

Front 3

What causes of syncope are most likely in younger patients? (3 main categories)

Back 3

Neurocardiogenic (e.g. vasovagal)
Congenital or inherited heart disease (e.g. HCM, LQTS)
Psychogenic causes (e.g. conversion disorder)

Front 4

What are the four most common etiologies of syncope in middle-aged patients?

Back 4

Neurocardiogenic (vasovagal)
Orthostatic changes.
Structural heart disease (CAD)
Arrhythmias

Front 5

What are four common causes of syncope in older patients?

Back 5

Orthostatic hypotension
Obstructive cardiac lesion
Arrhythmias from structural heart disease
Bradyarrhythmias

Front 6

What are the five broad categories for causes of syncope?

Back 6

Neurally mediated
Orthostatic
Cardiac arrhythmias
Structural cardiopulmonary disease
Cerebrovascular

Front 7

What are the three causes of Neurally mediated syncope?

Back 7

Vasovagal
Carotid sinus syndrome
Situational

Front 8

Name 3 triggers can lead to Situational syncope

Back 8

micturition syncope
cough syncope
defecation syncope
cold to hot
breath holding
post-exercise
post-prandial

Front 9

What is the mechanism for Carotid Sinus Syndrome syncope?

Back 9

A hypersensitive carotid baroreceptor causes marked bradycardia with stimulation of the neck, leading to decreased cerebral perfusion and syncope.

Front 10

For patients with syncope related to orthostatic hypotension, what are three different possible causes of their syncope?

Back 10

Choose from:
Autonomic failure, (multiple system atrophy, Parkinson's with autonomic failure)
Secondary autonomic failure (diabetic or amyloid neuropathy)
Post-exercise or post-prandial deficits
Drug-induced orthostasis
Volume depletion

Front 11

Name three types of drugs that can cause orthostatic hypotension.

Back 11

Alcohol,
Vasodilators,
Diuretics,
Phenotiazines,
Antidepressants

Front 12

How can you narrow down causes of syncope in the physical exam? (give 2 tests/findings)

Back 12

orthostatic blood pressures
carotid bruits
parkinsonian features?
normal cardiac exam?

ECG

Front 13

A patient presents with a history of syncope. You've ruled out drugs or non-syncopal TLOCs. Name three elements of the history that can point to a cardiogenic cause.

Back 13

Looking for history of:
MI,
Heart surgery,
Known valvular heart disease,
History of palpitations,
Family history or risk of inherited heart condition (sudden cardiac death, or known disease).
Syncope on exertion,
Syncope with chest pain, or other cardinal symptoms of CV disease.

Front 14

In a patient with recurrent syncope, what etiology is indicated by this ECG?

Back 14

Analysing the ECG:
T-wave appears abnormal, looks like an abnormally prolonged QT interval, so you should work out the value of QTc:
QTc = QT/sqrt(RR)
QT = 0.56 s
RR = 0.92 s
QTc = 0.58 s

A QTc of >0.46 s is prolonged in all age groups, so this ECG points to Long QT syndrome.

Front 15

In a patient with recurrent syncope, what etiology is indicated by this ECG?

(hint: look at V1 and V2)

Back 15

The RBBB pattern, with ST elevation in V1 & V2 is indicative of Brugada Syndrome.

Front 16

What is the main concern for patients with Brugada syndrome?

Back 16

SCD

Front 17

What causes of syncope can be picked up by an ECG or Implantable Loop Recorder (ILR)?
(give 3)

Back 17

Some choices:
Sinus bradycardia,
Conduction defects (BBBs, AV blocks),
Long QT syndrome,
Brugada syndrome
Arryhthmogenic right ventricular dysplasia

Front 18

What causes of syncope can be picked up by an echocardiogram? (give 2)

Back 18

Syncope due to:
Ventricular dysfunction,
Valvular heart disease,
Hypertrophic cardiomegaly,
Other structural or flow-related defects (e.g. pulmonary hypertension, tumours, etc.)

Front 19

When might you initiate an exercise treadmill test in a patient with syncope?

Back 19

To confirm a history of exercise-induced syncope, and rule out some rare conditions, after other investigations have proven fruitless.

Practically, it is very rarely indicated in an investigation of syncope.

Front 20

What are three ways to non-pharmacologically help a patient avoid episodes of neurocardiogenic syncope?

Back 20

Many ways:
Avoid triggering events,
Help them recognize premonitory symptoms (nausea etc)
Teach them maneuvers to avoid the syncope (leg crossing, hand grip/arm tensing, adopting supine position)
Avoid volume depletion,
Avoid prolonged upright posture, or hot confining environments.
Avoid vasodilator medications.

Front 21

What are two indications for an implantable pacemaker?

Back 21

3rd degree and advanced 2nd degree AV block with symptoms.
Heart block with pauses >3sec or escape rate <40
Fascicular blocks with 2nd or 3rd degree block, or alternating bundle branch block,
Syncope, thought to be heart block.

Front 22

What are the primary indications for an Implantable Cardioverter Defibrillator?

Back 22

Patients with:
Documented VT and structural heart disease,
An Electrophyisological Study (EPS)-induced monomorphic VT in patients with previous MI.
Patients with inherited cardiomyopathies or channelopathies with documented VT.

Front 23

What is the goal of ICD therapy?

Back 23

reduction in SCD

Front 24

What is the advantage of biventricular pacing?

Back 24

For patients with cardiac dyssynchrony (caused by bundle branch blocks, AV nodal dysfunction, with EF< 30%) it can improve:
Suboptimal ventricular filling,
Reduced LV pressure rise,
Mitral regurgitation,
Septal dysfunction