CHF + Syncope Flashcards
CHF Exacerbations
What are the factors implicated in worsening CHF status?
- non-compliance with salt restriction (22%) other noncardiac causes (20%)
- pulmonary infectious processes
- use of enalapril maleate, candesartan cilexetil, and metoprolol succinate medications (15%) i.e. angiotensin II antagonist, an angiotensin-converting enzyme inhibitor
- use of antiarrhythmic agents in the past 48 hours (15%)
- arrhythmias (13%)
- calcium channel blockers (13%)
- inappropriate reductions in CHF therapy (10%).
approximately two thirds of the economic burden of CHF is due to hospitalizations for worsening clinical status.
CHF Exacerbations
What are the demographics?
Pts with CHF event vs without
What are the Clinical findings?
Based on table 1: men more than women, mean age 63y, and ischemic cause
Pts with CHF event vs without
crackles
peripheral edemea
third heart sound
JVD
tricuspid regurgitaiton
mitral regurgitation
hepatomegaly
CHF Exacerbations
What are the treatments?
- oral diuretics in 56% of cases
- ntravenous diuretics in 48%
- addition of a new diuretic in 19%
- Intravenous inotropes were administered in 16%
- intravenous digoxin in 10%
- Nitrates were started or increased in 9% of cases
- Noncompliance with medications, uncontrolled hypertension, and coronary ischemia were 7%, 2%, and 2% respectively
CHF Exacerbations
Ensuring that all patients with
CHF receive vaccination for influenza and pneumococcus might also reduce these causes of CHF worsening
Syncope- Evaluation and Differential Diagnosis
What is syncope? - What are the defining characteristics?
What are other causes of a syncopal episode?
A sudden, brief, and transient loss of consciousness caused by cerebral hypoperfusion
rapid onset with transient loss of consciousness usually accompanied by falling, followed by spontaneous, complete, and
usually prompt recovery without intervention
seizures, cataplexy, metabolic disorders, acute intoxications, vertebrobasilar insufficiency, TIA, CVA, and psychogenic pseudosyncope
Syncope- Evaluation and Differential Diagnosis
Syncope Fact!
Approximately 25% of patients with syncope will experience another event within two years.
Syncope- Evaluation and Differential Diagnosis
What is syncope classified as (what body system)?
What are rare causes of syncope?
Cardiac - however Neurally mediated syncope is the most common type, comprising approximately 45% of cases
* Cardiac syncope occurs in approximately
20% of syncope presentation
subclavian steal syndrome
pulmonary embolism
acute myocardial infarction
acute aortic dissection
leaking aortic aneurysm
subarachnoid hemorrhage
cardiac tamponade
Syncope- Evaluation and Differential Diagnosis
Does the presence of cardiovascular disease effect one’s chances of syncope?
The presence of cardiovascular disease predicts a cardiac etiology of syncope with 85% to 94% sensitivity and 64% to 83% specificity.
Syncope- Evaluation and Differential Diagnosis
WTF is presyncope?
poorly studied
It should have similar evaluations as a syncope (assessments/tests)
Syncope- Evaluation and Differential Diagnosis
Classification of Syncope
Syncope- Evaluation and Differential Diagnosis
Physical Examination
Elavulation of Syncope (Show me)
The examination should focus on initial vital signs; orthostatic blood pressure measurements. Vascular (pulses and
carotid bruits), cardiac, pulmonary (evidence of congestive heart failure), abdominal, rectal, and skin/nail (anemia) signs should also be assessed.
Cardiac and unexplained syncope most can both end in implantable loop recorder as the final evaulation
If you’re considering neurally mediated syncope it may lead you to cardiac syncope
Syncope- Evaluation and Differential Diagnosis
Explain the carotid hypersonsitivity test/carotid sinus massage!
What does it mean if the patient tests positive?
This maneuver should be avoided in patients who have had a stroke or TIA in the past 3 months or patients with carotid bruits
Carotid sinus massage can be considered in patients older than 40 years to confirm the diagnosis of carotid sinus hypersensitivity. The maneuver is positive when it produces an asystolic or ventricular pause longer than
three seconds or a decrease in systolic blood pressure of at least 50 mm Hg. The test is performed while the patient is supine, with five to 10 seconds of massage consecutively to each carotid sinus. It should be performed initially on the right because the maneuver is more often positive on this side. If results are negative, it should be repeated with the patient upright at approximately 60 to 70 degrees
They have carotid sinus syndrome
This is determining whether syncope will occur
Syncope- Evaluation and Differential Diagnosis
Explain how ECGs can be useful for syncope considering they have a low diagnostic yeild in terms of detecting arrhythmias on a single ECG!
What are the Electrocardiographic Abnormalities Suggesting an Arrhythmic Syncope?
ischemic, structural, or conduction abnormalities may be identified. Any ECG abnormality or change from baseline increases the risk of arrhythmia or death within 1 year of a syncopal event
Abnormal ECG findings occur in about 90 percent of patients with** cardiac-induced syncope** but in only 6 percent of patients with neurally mediated syncope
Syncope- Evaluation and Differential Diagnosis
Pertinent Historical Information in the Evaluation
of Syncope
(show me)
Syncope- Evaluation and Differential Diagnosis
Pertinent Historical Information in the Evaluation
of Syncope
(show me) - continued
Syncope- Evaluation and Differential Diagnosis
Diagnostic Evaluation of Syncope
(show me)
Syncope
What are the 4 categories the syncope is classified into?
How common is it in adults?
reflex mediated
cardiac
orthostatic
cerebrovascular
20 to 50% of adults experience one or more
episodes during their lives
More than 75% of persons older than 70 years will
experience syncope at least once
Syncope
Diagnosing the Cause of Syncope Following a Verified Syncopal Event
(show me)
Syncope
Possible Diagnoses Related to Time and Background of Syncopal Attack
(show me)
