STEP 2 CARDS: Syncope

Question 1

a type of recurrent reflex syncope that primarily occurs in individuals with carotid sinus hypersensitivity when pressure is applied to the carotid sinus

Answer 1

Carotid sinus syndrome

Question 2

increased carotid sinus sensitivity (due to, e.g., increased baroreceptor or peripheral receptor response)

Answer 2

Carotid sinus syndrome

Question 3

How do we diagnose carotid sinus syndrome?

Answer 3

carotid sinus hypersensitivity confirmed, e.g., pause in heart rate ≥ 3 seconds AND/OR fall in systolic blood pressure ≥ 50 mm Hg when pressure is applied by carotid sinus massage

Question 4

Reflex, cardiac, or orthostatic: carotid sinus syndrome

Answer 4

reflex

Question 5

Why do we use the tilt table test in patients with reflex syncope?

Answer 5

To figure out the phenotype-> is it carotid sinus syndrome, vasovagal, situational?

Question 6

Describe the tilt table test

Answer 6

A procedure that is used to determine if vasovagal or orthostatic syncope is present. The patient is strapped onto a tilt table in a supine position for 15 minutes and then raised passively to an angle of around 70°. Normally, the patient’s heart rate increases while the blood pressure barely changes. The test is positive if the patient develops hypotension (systolic blood pressure < 90 mm Hg) and bradycardia (vasovagal) or slow progressive hypotension (orthostatic) with presyncope or syncope.

Question 7

What are the broad categories of syncope?

Answer 7

Reflex, cardiac, or orthostatic

Question 8

What are the two major categories of cardiac syncope?

Answer 8

mechanical (valve, hocm) and arrythmia

Question 9

What type of syncope can occur while supine?

Answer 9

arrythmia

Question 10

standing up/postural change PLUS insufficient counterregulation, i.e., reflex tachycardia and vasoconstriction are impaired (due to autonomic dysfunction) or overwhelmed → dependent pooling of blood → hypotension (can be symptomatic or asymptomatic)

Answer 10

orthostatic hypotension

Question 11

causes of orthostatic hypotension

Answer 11

Hypovolemia (e.g., dehydration, hemorrhage, use of diuretics such as thiazides)
Medications that cause vasodilation or limit tachycardia (e.g., beta blockers, alpha blockers, calcium channel blockers)
Prolonged bed rest
Age-related loss of baroreceptor sensitivity
Anemia
Pregnancy

Question 12

What are the major categories we can separate syncope into based on the physiology?

Answer 12

decreased cardiac output as seen in cardiac and hypovolemia related syncope
and
decreased peripheral resistance as seen in issues with decreased sympathetic tone (due to drugs, parkinsons, autonomic failure) or increased parasympathetic tone (vasovagal, carotid sinus syndrome)

Question 13

Syncope with exertion can be seen in…

Answer 13

aortic stenosis, pulm htn, HOCM, and coronary artery disease

Question 14

Syncope in the setting of CAD and or HFrEF is likely due to….

Answer 14

Arrythmia
Sudden syncope without prodrome in the setting of coronary artery disease or heart failure with reduced ejection fraction is likely to be arrhythmogenic in nature and should be evaluated with 24-hour ECG monitoring.

Question 15

Chronic orthostatic intolerance is caused by____________________________-

Answer 15

Chronic orthostatic intolerance is caused by autonomic dysfunction.