Clinical Cardiac Part 4 Flashcards
(134 cards)
1
Q
What is syncope?
A
Transient, self-limited loss of consciousness due to cerebral hypoperfusion
2
Q
What are the characteristics of syncope?
A
Rapid onset
Brief duration
Recovery is spontaneous and complete
3
Q
What are the three categories of syncope?
A
1) Neurally mediated
2) Cardiac
3) Orthostatic hypotension
4
Q
What is the time frame for neurally mediated syncope?
A
Transient
5
Q
What is the time frame for orthostatic hypotension?
A
Chronic
6
Q
What are the subtypes of neurally mediated syncope?
A
Vasovagal syncope
Carotid sinus syndrome (reflex)
Situational syncope (reflex)
7
Q
What is cardiac syncope?
A
Due to arrhythmias -> structural cardiac disease that cause a decrease in cardiac output
8
Q
What are the subtypes of orthostatic hypotension?
A
Initial (immediate)
Classic
Delayed
Neurogenic
9
Q
What are examples of syncope mimics?
A
Seizures
Sleep disturbance (cataplexy or narcolepsy)
Trauma (head injury)
Metabolic (hypoglycemia, acute intoxications)
Psychogenic/pseudo-syncome
10
Q
What is the trimodal incidence of first syncopal episode?
A
20
60
80
11
Q
What is the most common type of syncope?
A
Neurally mediated
12
Q
What type of syncope occurs with change in position?
A
Orthostatic hypotension
13
Q
What type of syncope occurs primary when the patient is supine?
A
Cardiac syncope
14
Q
What type of syncope happens when a patient has fatigue, nausea, or vomiting after?
A
Neurally mediated syncope (vasovagal)
15
Q
What type of syncope occurs when a patient is coughing, pooping, eating, laughing, or urinating?
A
Neurally mediated syncope (situational)
16
Q
What type of syncope occurs when a patient has emotional distress, fear, pain, prolonged standing, warm, or crowded area?
A
Neurally mediated syncope (vasovagal)
17
Q
What type of syncope occurs with exertion?
A
Cardiac syncope (arrhythmia, structural heart disease)
18
Q
What type of syncope occurs with head movement, shaving, or tight collar?
A
Neurally mediated syncope (carotid sinus)
19
Q
What are short term risk factors for syncope?
A
Male sex Old Palpitations Exertional syncope HF Structural heart disease CAD Trauma
20
Q
What are long term risk factors for syncope?
A
Male sex
Old
Absence of nausea/vomiting preceding syncopal event
VA
21
Q
What does the San Francisco Syncope Rule predict?
A
Serious outcomes at 7 days in patients presenting with syncope or near syncope
22
Q
What are the aspects of the San Francisco Syncope Rule?
A
Congestive heart failure history Hematocrit < 30% EKG abnormal (EKG changes, no sinus rhythm) SOB symptoms Systolic BP < 90 mmHg
23
Q
What is the equation for cardiac output?
A
Rate x Stroke Volume
24
Q
Where is blood pooled when we are standing and what does that result in?
A
Legs
Decreased venous return
25
Decreased return to the heart activates what?
Sympathetic nervous system
26
What are the orthostatic intolerance symptoms with neurally mediated syncope?
Dizziness
Lightheadedness
Fatigue
27
What are the autonomic activation symptoms in neurally mediated syncope?
```
Diaphoresis
Pallor
Palpitations
Nausea
Hyperventillation
Yawning
```
28
What happens to the eyes in neurally mediated syncope?
Remain open and deviate upwards
Pupils dilated
Roving eye movement may occurs
29
Does urinary incontinence happen with neurally mediate syncope?
Maybe
30
Does fecal incontinence happen with neurally meditated syncope?
No
31
Does post-episode confusion happen with neurally mediated syncope?
No
32
What is the prodrome for neurally mediated syncope?
```
Abdominal pain
Diaphoresis
Nausea
Blurred vision
Dizziness
Lightheadedness
Vertigo
Slow pulse
```
33
What is the definition of orthostatic hypotension?
Reduction in systolic BP of > 20 mmHg or diastolic > 10 mmHg within 3 minutes of standing
34
What are the symptoms with orthostatic hypotension?
```
Light-headedness
Dizziness
Presyncope with sudden postural change
Generalized weakness
Fatigue
Cognitive slowing
Leg buckling
Headache
```
35
Is syncope preceded by warning symptoms in orthostatic hypotension?
Yes
36
What is the most concerning type of syncope?
Cardiac syncope
37
Is syncope preceded by warning symptoms in cardiac syncope?
No
38
What is the one symptom associated with cardiac syncope?
Palpitations
39
What history is a risk factor for cardiac syncope?
Family history of sudden death
40
What is the best approach for a patient with syncope?
Detailed history
41
What are the key elements of history taking in syncope?
LOC attributable to syncope?
Is there a history of CV disease?
Are there clinical features to suggest a specific cause of syncope?
42
What causes 5-15% of syncope cases?
Medications (do medication reconcilitation)
43
What can meds cause in terms of syncope?
Orthostatic hypotension
Sedation
Symptomatic bradycardia
QT interval prolongation
44
What should be focused on for the PE in syncope?
Vital signs
Cardiovascular
Neuro examination
Orthostatic vitals (BP and pulse)
45
Any ECG abnormality or change from baseline increases the risk of arrhythmia or death within how long from a syncopal event?
One year
46
What labs should be order for syncope?
CBC
CMP
BNP
Troponin
47
What should not be done in cases of syncope without focal neurologic findings or head injury?
CT
MRI
Carotid artery imaging
48
What should be done if you suspect neurogenic syncope?
Autonomic evaluation
49
What should be done if you suspect reflex neurally mediated syncope?
Tilt-table testing
50
What should be done if you suspect cardiac syncope?
Cardiac monitoring
51
What is tilt-table testing good for?
Suspected VVS
Suspected delayed OH
Distinguished convulsive syncope from epilepsy
Establish diagnosis of pseudosyncope
52
Patients with exertional syncope you order what?
Stress testing
53
Patients with syncope and suspected structural heart diagnosis you order what?
TTE
54
Patients with syncope and suspected arrhythmia you order what?
EPS (electric physiologic study)
55
What are the four different types of cardiac monitors?
1) Holter
2) Event monitor
3) External loop recorder
4) Internal monitor
56
When is a holter monitor used?
Symptoms recur within 24-72 hours
57
What is a holter monitor?
Portable, continuous correlation with diary
58
What is an event monitor?
Patient-activated via analog phone to station
59
When is an event monitor used?
Symptoms recur within 2-6 weeks
60
What is an external loop recorder?
Continuous, patient activated or auto triggered, get data around event too, via cell phone
61
When is external loop recorder used?
Symptoms recur within 2-6 weeks
62
What is an internal monitor?
SubQ, battery lasts 2-3 years, triggered by patient or family
63
When is a internal monitor used?
Recurrent, infrequent, unexplained syncope of suspected arrhythmic origin
64
When do you manage syncope outpatient?
Presumed neurally mediated
| Cardiac syncope but not serious medical condition
65
When do you manage syncope with observation?
```
Age > 50
Hx of cardiac disease
Functioning cardiac device
Abnormal ECG
Family history of sudden cardiac death
Symptoms do not point to neurally mediated syncope
```
66
What do you manage syncope with admission?
```
Major cardiac arrhythmia
Serious CV condition (cardiac ischemia, aortic stenosis, heart failure, pulmonary embolism, hypertrophic cardiomyopathy)
Anemia
Major trauma
Persistent abnormal vital signs
```
67
What is the treatment for neurally mediated syncope?
Increase central blood volume and cardiac output
Reassurance
Avoidance of triggers
Plasma volume expansion with fluid/salt
Physical counterpressure maneuvers of limbs (leg crossing or handgrip)
68
What is the treatment for orthostatic hypotension?
```
Remove reversible causes
Patient education on standing up
Compression stockings
Counterpressure maneuvers
Expanded intravascular volume by increasing dietary fluid and salt
```
69
What drugs treat orthostatic hypotension?
Midodrine
| Fludrocortisine
70
What is the treatment for cardiac syncope in patients with a suspected arrhythmic etiology?
EPS
71
What is the treatment for bradyarrhythmias?
Cardiac pacing for sinus node disease and AV block
72
What is the treatment for tachyarrhythmias?
Ablation
Antiarrythmic drugs
Cardioverter-defibrillators
73
HTN doubles the risk of what?
Cardiovascular disease
74
What are modifiable risk factors in HTN?
```
Smoking
DM
Dyslipidemia
Obesity
Low fitness
Unhealthy diet
```
75
What are relatively fixed risk factors in HTN?
```
Chronic kidney disease
Family history
Increased age
Low socioeconomic/educational status
Male sex
Sleep apnea
Psychosocial stress
```
76
What is the most common cause of death in patients with HTN?
Structural/functional adaptations of HTN leading to LVH, HF, atherosclerotic CAD, microvascular disease, cardiac arrhythmias, A. fib
77
What are brain consequences of HTN?
Stroke
Impaired cognition/dementia
HTN-encephalopathy
78
What are kidney consequences of HTN?
Renal injury
| End stage renal disease
79
What are peripheral arteries consequences of HTN?
Peripheral artery disease
80
What is primary HTN?
No specific underlying disorder
81
What is secondary HTN?
Elevated BP with specific underlying disorder
82
What is asymptomatic severe HTN?
>180/110 without end organ damage
83
What is a hypertensive emergency?
Severe BP elevation >180/110 with end organ damage
84
What is elevated BP?
120-129/<80
85
What is stage 1 hypertension?
130-139/80-89
86
What is stage 2 hypertension?
> 140/90
87
How do you diagnose HTN?
Average of greater than two reading on greater than two occasions
88
How do you diagnose HTN in children?
SBP > 95% for age, sex, and height
| Pre-HTN: 90-95%
89
How do you diagnose HTN in pregnant women?
SBP > 140 OR DBP > 90
90
What should you ask in women regarding HTN?
Did you have HTN when you were pregnant
91
When do you take BP in the office?
After patient has sat quietly for 5 minutes
92
What do you look for in HEENT exam for HTN?
Retinopathy
93
What do you look for in neck exam for HTN?
Carotid bruit
94
What do you look for in CV exam for HTN?
Rate
Rhythm
Murmur
95
What do you look for in lung exam for HTN?
Rales
| Effusions
96
What do you look for in abdominal exam for HTN?
Aortic dilation
| Bruit
97
What do you look for in extremities for HTN?
Edema
| Quality of femoral/pedal pulses
98
What do you order if you suspect HTN?
```
CBC
CMP
Lipid panel
TSH
UA
EKG
```
99
How do you treat someone with normal BP?
Promote lifestyle habits
100
How do you treat someone with elevated BP?
Non-pharmacologically
101
How do you treat someone with stage 2 hypertension?
Non-pharmacological therapy
BP-lowering medication (two from two different classes)
Reassess in one month
102
How do you treat someone with stage 1 HTN and a greater than 10% risk of cardiovascular event in 10 years?
Non-pharmacological therapy
BP-lowering medication
Reassess in one month
103
How do you treat someone with stage 1 HTN and without a risk for a cardiovascular event in 10 years?
Non-pharmacological therapy
| Reassess in 3-6 months
104
What do you check in patients after initiating them on HTN medication?
Assess electrolytes and renal function
105
Who is automatically considered high risk when it comes to HTN?
Diabetes
Chronic kidney disease
Age > 65
106
What is the risk calculator called?
ASCVD (atherosclerotic cardiovascular disease)
107
What is goal BP for patients with known CVD or 10-year event risk of greater than > 10%?
<130/80
108
What is the goal BP for patients with no clinical CVD and 10-year event risk less than 10%?
<130/80
109
What is the goal BP of adults older than 65 who are ambulatory and not institutionalized?
<130
110
What is the goal BP in adults older than 65 with comorbidities and limited life expectancy?
Individualized goal based on clinical judgement and patient preference (don't want to drive BP too low)
111
What is lifestyle management for HTN?
```
Weight reduction (less than 25 BMI)
Dietary salt intake
Adapt DASH-type dietary
Moderation of alcohol consumption
Physical activity
Enhanced intake of potassium
```
112
How much did the DASH diet lower BP?
-11.2 mmHg
113
What are first line BP drugs for whites?
ACEi
| ARBs
114
What are first line BP drugs for blacks?
CCBs
| Diuretics
115
What are first line BP drugs for DM?
ACEi
| ARB
116
What are first line BP drugs for CHD or CHF?
ACEi
ARB
Beta-blockers
117
What are first line BP drugs for BPH?
Alpha-blockers
118
What are first line BP drugs for A fib?
CCBs (non-dihydropiridines)
| Beta-blockers
119
What to consider when choosing BP medications?
```
Generics
Once daily dosing
Non-affected by food
Price
Combination pills
```
120
What is the first choice within ACEis?
Lisinopril
121
What is the first choice within ARBs?
Valsartan
122
What is the first choice within thiazide/diuretics?
Chlorthalidone
123
How do you reassess after starting BP medication?
```
Detection of orthostasis
ID white coat effect
Document adherence
Monitor response
Reinforce importance of treatment and assistance in achieving BP target
```
124
Is there evidence that acute inpatient treatment of severe asymmptomatic hypertension improves outcomes?
No
125
What is the treatment for hypertensive urgency?
BP lowered gradually <160/100 but not acutely <20-25% of the MAP over several days to weeks
Intensify therapy every 2-4 weeks
126
What are the symptoms of HTN emergency?
Agitation, delirium, stupor, seizures, nausea/vomiting
Focal weakness, numbness, dysarthria, aphasia
Visual disturbance, fresh flame hemorrhage, exudates, papilledema
Chest discomfort, palpitations
Acute severe back pain
Dyspnea
Cerebral infarction
Pulmonary edema
127
What do you order if you suspect HTN emergency?
```
EKG
CXR
UA
Serum electrolytes
Creatinine
Cardiac biomarkers
CT brain
```
128
What are the general rules for treating HTN emergency?
Lower MAP gradually
10-20% 1st hours
5-15% over the next 24 hours
129
How do you treat the brain in HTN emergency?
Differentiate stroke/trauma (tolerate higher BP) from HTN encephalopathy
Clevidipene, nicardipine, fenoldapam, nitroprusside
130
How do you treat acute HF with HTN emergency?
Nitroprusside
| Nitroglycerin (vasodilators, reduce preload)
131
How do you treat acute coronary syndrome with HTN emergency?
```
Nitroglycerin
Nicardipene
Clevidipene
Metoprolol
Esmolol (reduce myocardial O2 requirement)
```
132
How do you treat the vasculature with HTN emergency?
Rapid lowering with IV esmolol
133
How do you treat the kidney with HTN emergency?
Fenoldapam
134
What percentage of patients in the US have resistant HTN?
15.3%
