Palpitations and Syncope

Question 1

What is Syncope?

Answer 1

• Loss of consciousness and postural tone
• Rapid onset
• Variable warning symptoms
• Spontaneous/complete/usually prompt recovery without intervention

Question 2

Causes of Syncope

Answer 2

• The VAST MAJORITY of causes (of palpitations/tachycardia) are usually BENIGN rather then malignants
• Neurally-mediated reflex syndrome
• orthostatic hypotension
• cardiac arrhythmias
• Structural cardiovascular disease

Question 3

Whats the impact of Syncope

Answer 3

40% people will experiance once in their life
1-6% hospital admissions
1% emergency room events
10% elderly fall

6% results in major morbidity
minor injury in 29%

Sufferers are sometimes not able to drive»_space; lifestyle and environmental impact

Question 4

Most syncope involves a complex of something going on with the

Answer 4

HEART the BRAIN and the AUTONOMIC NS

**remember there are many autonomic modifiers that affect the heart, which can result in syncope

Question 5

Age dispersion of Syncope

Answer 5

Cluster during the teenage years, decreases in middle age and then begins to strongly increase with age again.

Question 6

Disorders that mimick syncope

Answer 6

• With loss of consciousness ie; seizure disorders, concussion
• without loss of consciousness ie; psychogenuc “pseudo-syncope’

Question 7

What should your diagnostic plan for dealing with the patient be
most important?**

Answer 7

1) History*******
2) Examination
3) Appropriate Investigations: Rhythm documentation, assess for structural heart disease.
4) Diagnosis by exclusion: rule out any significant cardiac or neurological disease

**No cause is found in ~35-50% patients

Question 8

Patient history is ESSENTIAL!

Answer 8

Circumstances of recent event

• eyewitnesses
• symptoms at onset

Previous events

Past medical history (what else is going on)

• cardiac
• neurological
• medication/drug history

Pertinent family history
-cardiac disease, sudden death, metabolic disorders

Question 9

Types of tests we do to try find out cause

Answer 9

ECG, more prolonged monitering.

Provovatie tests: to try provoke hypotension or tachycardia.

Neurological Tests: ONLY do if you think there could be a seizure issue/neurological cause. Has a very low yield.

Only the history and physical examination has a high yield.

Question 10

Neurally-Mediated Syncoope

Answer 10

• Vasovagal Syncope (VVS)
• Carotid Sinus Syndrome (CSS)

-Situational Synchope:
> post-micturition; cough etc
> pain/psychological etc

• Physiologic Reflex Mechanism
  
  1. Cardioinhibitory (HR)
  2. Vaso depressor

Question 11

Whats seen on an ECG with a recurrent NM syncope

Answer 11

Sudden stopping of heat beats, no cardiac activity.

Drifting due to the patients starting to breathe in a funny fashion, bc there’s no blood going around to maintain cerebral perfusion. if it carries on > ‘aginal breathing’

Question 12

Orthostatic Hypotension

Answer 12

Drug-induced (very common)

• diuretics
• vasodilators

Primary Autonomic failure

• multiple system atrophy
• parkinsion’s disease
• Postural orthostatic tachycardia syndrome (POTS)

Secondary Autonomic Failure

• Diabetes
• Alcohol
• Amyloid

Question 13

What do all these different causes mean in terms of treatment?

Answer 13

That we have to be very careful and tailor treatment to the individual patient. Drug strategies and interventions are at the bottom of the list, and most of the management of syncope is ruling out any major causes and reassuring the patient.

Teaching the patient about situations to avoid, movements they can do, hydration etc

Question 14

Cardiac Syncope

Answer 14

• Potentially life-threatening
• May be warning of significant CV disease
• Initiate assessment/treatment promptly

Question 15

Types of Syncopes due to cardiac arrhythmias

Answer 15

Bradyarrhythmias

• sinus arrest
• High grade or acute complete AV block
• can be accomponied by vasodilation (VVS, CSS)

Tachyarrhythmias

• atrial fibrillation/flutter with rapid ventricular rate
• Paroxysmal SVT or VT
• Torsade de pointes

Very small %of these issues are actually discovered

Question 16

Palpitation

Answer 16

• Awareness of heart rate or rhythm change
• Usually transient and benign: simple ectopic beats, often nocturnal or noted during rest, exertional less common

-malignant potential small

Question 17

Palpitation and tachycardia symptoms

Answer 17

Symptom - history is key

Physical examination - exclusion

Differential diagnosis

Investigation

Question 18

Management

Answer 18

-Exclude SHD/risk stratify
-Reassurance
-Treatment :
>may cause more harm then good!!
> side effects/pro-arrhythmias
>Beta blockade vs Class I agents

Question 19

Examples of palpitation/tachycardia

Answer 19

Incessant ectopy: may reflect underlying cardiac issue

SVTs: almost ALWAYS benign, curable

ECTOPY in presense of SHD: trigger for malignant arrhythmias

Question 20

CASE 1
20yr old
Blackouts since teenager
ED after LOC at party
no other history
Now recovering

Answer 20

History:
-no drugs/alcohol of significance, not exercising, not unwell, no family history
Echo - MVP, mild MR, PFO

Examination: is she hypotensive? Needle tracts? Diarrhoea, URT infection?

Treatment: Reassurence, Vit E/Primrose oil, review.

But then she collapsed again, turns out she had a malignant event.

Question 21

Long QT Syndromes

Answer 21

Mechanism:

• abnormalities of Na+ and/or K+ channels
• SUsceptability to polymorphic VT

Prevalence:

• Drug-induced (common)
• Genetic (~rare)
• “concealed” forms (may be common)

Think about the medications you could use.

Question 22

CASE 2:
Atrial fibrillation;
Abnormal, irregular ECG, delta waves

24years old

Answer 22

Accessory pathway WOWW syndrome.

At a small risk of sudden cardiac death.

Question 23

CASE 3: 
75 years
Recurrent dizziness when standing
Blackout?
Witness history

Answer 23

Left bundle branch block. QRS completely disassociated from P wave
“Complete heart block”

Can definitely cause collapse

Needs pacemaker treatment.