Arrhythmias and Syncope Lecture Powerpoint

Question 1

Syncope definition

Answer 1

Transient loss of consciousness due to global cerebral hypoperfusion characterized by rapid onset, short duration, and spontaneous complete recovery (not lethargic upon return)

Question 2

Fundamental cause of transient drop in cerebral perfusion

Answer 2

Drop in BP resulting from decreased CO, decreased PVR, or a combo of both

Question 3

Diagnosis of syncope must rule out these 2 things

Answer 3

head trauma and epilepsy

Question 4

syncope is not a ____ it is a ____!!!

Answer 4

disease, symptom

Question 5

Syncopal recurrence is about __%

What are the 3 types of syncope and which are favorable and which are unfavorabe?

Answer 5

20,

• Reflex (neutrally mediated) syncope/vasovagal (favorable outcome)
• Orthostatic hypotension (favorable outcome)
• Untreated cardiac syncope (greater chance of mortality, unfavorable)

Question 6

Syncope is more common in ___ than ___, and more likely ___ in children than elderly

Answer 6

women, men, benign

Question 7

Most valuable diagnostic tools for syncope (3)

Answer 7

• history (details about episode)
• complete physical exam (including orthostatic blood pressure measurements)
• EKG

Question 8

Orthostatic blood pressure measurements

Answer 8

A series of 3 measurements going from lying, sitting, to standing, if systolic BP drop greater than 20 mmHg or diastolic 10 mmHg then considered positive (or if HR increases 20-30bpm or if patient becomes symptomatic)

Question 9

Sudden cardiac death may occur with ___% of cardiac syncope

Answer 9

30

Question 10

Most common cause of syncope is ___.

Second most common is ___.

Answer 10

Vasovagal (neurally mediated or reflex), Cardiac etiology

Question 11

Neurally mediated (reflex) syncope/vasovagal syncope mech of action

Answer 11

• Baroreceptors in carotid sinus and aortic arch monitor BP and HR by innervation of CN IX and X
• Decreased firing due to lack of stretch from baroreceptors activates brain stem to respond with sympathetic innervation to raise pressure
• Increased firing due to stretch from baroreceptors inhibits brain stem from responding with sympathetic innervation causing lowering of blood pressure as well as increase in vagal tone to heart to decrease HR

Question 12

Vasovagal/neurally mediated syncope never occurs when…

Answer 12

….lying down

Question 13

Tilt table test

Answer 13

Performed to diagnose suspicion of vasovagal/reflex syncope, no change in EKG but shifts in BP and heart rate are positive upon shifting orientation of table

Question 14

Situational syncope

Answer 14

A type of vasovagal/neurally mediated syncope episode brought on by specific activity, most often post defecation

Question 15

Carotid sinus hypersensitivity (charcot weiss baker syndrome)

Answer 15

Occurs when stimulation of carotid sinus causes bradycardia and hypotension often in elderly or with tight collars, can diagnose with carotid sinus massage

Question 16

Contraindications to carotid sinus massage (3)

Answer 16

• Carotid bruits
• recent MI
• History of CVA

Question 17

Orthostatic hypotension syncope etiology

Answer 17

-Sudden decrease in BP after standing or during standing after exertion due to volume depletion, drugs, or autonomic dysfunction, most common in elderly and rare in those less than 40 years of age caused by autonomic failure, drugs, hypovolemia, and treated with volume replacement, avoiding precipitating factors, treatment of underlying cause

Question 18

Cardiac syncope etiology

Answer 18

Known structural heart disease suggested, loss of consciousness during exertion or sudden onset of palpitations is characteristic, can be due to bradycardia, tachycardia, structural disease, and obstructive disease, can be brought on by drugs, hyper/hypothyroidism, or prolonged QT interval

Question 19

Long QT syndrome and how it relates to syncope

Answer 19

Problem with heart’s electrical system that is often asymptomatic until sudden syncopal episode, may be congenital or acquired, and is linked to sudden cardiac death and torsades de pointes

Question 20

DOC for torsades de pointes

Answer 20

-IV magnesium

Question 21

Should all athletes be screened for long QT because of its risk of sudden cardiac death?

Answer 21

No because of many false positives unless they have relevant family history

Question 22

1 treatment for long QT syndrome (and its supplement)

Answer 22

• IV magnesium followed (stabilize) by B blocker
• sometimes supplementary implantable cardioverter defibrillators in those with high risk for sudden cardiac death expected to live more than a year

Question 23

Brugada syndrome

Answer 23

Genetic condition channelopathy responsible for 4-12% of all sudden cardiac deaths, high risk, manifests with specific “saddle-like” pattern ST segment elevation in leads V1-V3 and right bundle branch block

Question 24

Brugada syndrome treatment

Answer 24

Implantable cardioverter defibrillator (ICD)

Question 25

Wolff parkinson White syndrome

Answer 25

Frequently encountered ventricular pre-excitation syndrome, presents asymptomatic or with a paroxysmal supraventricular tachycardia or atrial fib, has triggers such as exercise or drugs, presence of delta wave on QRS complex, most have good prognosis if asymptomatic

Question 26

Wolff parkinson white treatment both urgent (3) and non-urgent (1)

Answer 26

Urgent (in afib) - syncronized direct cardioversion, if hemodynamically stable can use vagal maneuvers or iv adenosine

Nonurgent - catheter ablation

Question 27

Hypertrophic cardiomyopathy 1st line treatment, 2nd line treatment, and alternative consideration

Answer 27

• B blockers
• Calcium channel blockers
• septal reduction

Question 28

Sick sinus syndrome and 3 subtypes

Answer 28

• Sinus node dysfunction (normal rate and rhythm with a pause) with associated symptoms
• 3 subtypes including chronic bradycardia, alternating sinus bradycardia with paroxysmal supraventriclar tachyarrhythmias, or tachybrady syndrome

Question 29

Treatment for sick sinus syndrome

Answer 29

-Pacemaker if symptomatic

Question 30

Syncope characteristics to look for in work up (4)

Answer 30

• complete loss of consciousness
• loss of postural tone
• recovery spontaneous and complete
• rapid onset and short duration

Question 31

Family history of sudden cardiac death or cardiac arrhythmias is indication for…

Answer 31

…frequent long term observation and monitoring of patients

Question 32

Specific signs of cardiac syncope (4)

Answer 32

• occurs during exertion
• occurs in lying down position
• family history of sudden cardiac death
• slow recovery from episode

Question 33

Diagnostic tests for syncope (4)

Answer 33

• EKG
• echocardiogram
• holter monitor
• external loop recorder

Question 34

Differences between holter monitor and external loop recorder

Answer 34

Holter monitor is for 24 hours, external loop recorder can stay on longer time and can shower with one just have to replace leads, press activation button on external loop recorder

Question 35

Syncope vs seizure

Answer 35

Syncope is due to transient loss of consciousness due to cerebral hypoperfusion
Seizure is due to abnormal electrical activity in brain

Question 36

Test that can differentiate between syncope and seizure

Answer 36

Electroencephalography (if abnormal likely seizure in origin)

Question 37

Hypertrophic cardiomyopathy and how it relates to syncope

Answer 37

Unexplained LVH resulting in impaired diastolic filling, most often genetic and asymptomatic but can lead to syncopal episode