Syncope

Question 1

What are the structural causes of cardiac syncope?

Answer 1

• Acute myocardial infarction
• Aortic stenosis
• Ischaemic cardiomyopathy
• Hypertrophic obstructive cardiomyopathy
• Cardiac tamponade

Structural causes are related to physical abnormalities in the heart.

Question 2

What are the electrical causes of cardiac syncope?

Answer 2

• Tachyarrhythmias (e.g., supraventricular tachycardia, ventricular tachycardia, ventricular fibrillation)
• Bradyarrhythmias (e.g., sick sinus syndrome, heart block)
• Inherited channelopathies (e.g., Brugada syndrome)

Electrical causes pertain to issues in the heart’s electrical conduction system.

Question 3

What is vasovagal syncope?

Answer 3

A type of reflex syncope commonly referred to as ‘fainting’.

It commonly occurs in response to triggers such as stress or pain.

Question 4

What are some examples of situational syncope?

Answer 4

• Following defecation
• Post-exercise
• Straining to pass urine

Situational syncope occurs in specific situations that trigger a fainting episode.

Question 5

What causes carotid sinus syndrome?

Answer 5

Hypersensitivity of the carotid sinus baroreceptor.

This can lead to reflex syncope due to changes in blood pressure.

Question 6

List some other causes of syncope.

Answer 6

• Orthostatic hypotension
• Pulmonary embolism
• Occult haemorrhage (e.g., subarachnoid haemorrhage, GI bleeding, ruptured aortic aneurysm)
• Head trauma
• Hypoglycaemia

These causes can lead to loss of consciousness from various underlying conditions.

Question 7

What are non-syncopal causes of blackouts?

Answer 7

• Seizures
• Psychogenic pseudosyncope
• Psychogenic non-epileptic seizures

These conditions can mimic syncope but are not due to loss of consciousness.

Question 8

What questions should be asked about the patient’s experience before the blackout?

Answer 8

• What were they doing/any triggers?
• Exertional syncope (cardiac)
• After exercise (vasovagal/orthostatic hypotension)
• Head movements/pressure on neck (carotid sinus syndrome)
• Prolonged standing (orthostatic hypotension)
• Pain (vasovagal)
• Repeated episodes after defecation/micturition/swallowing/coughing (situational syncope)
• After a meal (vasovagal or orthostatic hypotension)

These questions help identify potential triggers and causes of the blackout.

Question 9

What prodromal symptoms may indicate a vasovagal episode?

Answer 9

• Feeling warm/hot
• Sweating
• Nausea

Prodromal symptoms can precede a fainting episode and help in diagnosis.

Question 10

What should be observed during the blackout?

Answer 10

• Protective measures taken
• Tongue biting (lateral for epilepsy, tip for vasovagal)
• Incontinence of bowels or bladder (epilepsy)
• Duration of loss of consciousness
• Appearance during blackout (e.g., pallor, eyes closed/open)

These observations help differentiate between syncope types.

Question 11

What duration of loss of consciousness suggests syncope?

Answer 11

Less than 30 seconds.

Longer durations may indicate other conditions such as seizures.

Question 12

What duration of loss of consciousness suggests psychogenic causes?

Answer 12

Over 5 minutes.

This duration is less typical for syncope and more indicative of psychogenic issues.

Question 13

What are important questions to ask after the blackout?

Answer 13

• Any injuries sustained during the blackout?
• Confusion or amnesia after consciousness regained?
• Focal neurological signs (e.g., weakness down one side)

These questions help assess the aftermath and potential complications.

Question 14

What should be included in a full set of observations during examination?

Answer 14

• Lying and standing blood pressure to assess for postural drop

A significant drop indicates orthostatic hypotension.

Question 15

What initial investigations should be carried out in an emergency setting?

Answer 15

• Blood glucose for hypoglycaemia
• ECG for arrhythmias and structural abnormalities
• Blood tests for electrolyte abnormalities, anaemia, inflammatory markers, AKI
• Transthoracic Echocardiography for suspected structural heart disease
• 24-hour ambulatory blood pressure monitoring
• Implantable loop recorders if necessary

These investigations help determine the cause of syncope.

Question 16

What is the driving advice for patients with unexplained syncope?

Answer 16

Must inform the DVLA and their license will be revoked for 6 months (12 months if Group 2).

Driving regulations are strict due to safety concerns.

Question 17

What should be done for patients with suspected cardiac syncope?

Answer 17

Refer for specialist review within 24 hours.

Timely referral is crucial for diagnosis and management.

Question 18

What is a characteristic finding in myoclonic jerks during vasovagal syncope?

Answer 18

Common occurrence of myoclonic jerks.

This can help distinguish it from other conditions.

Question 19

What should be done for patients with suspected epilepsy?

Answer 19

Refer to a first fit clinic.

This is essential for proper evaluation and management.