Syncope - Low/Med Priority

Question 1

What is syncope?

Answer 1

a sudden and temporary loss of consciousness
-often referred to as “fainting”

Question 2

Are the majority of cases of syncope very dangerous?

Answer 2

majority of cases are benign, with pts having a quick and complete recovery

Question 3

What are most complications from syncope a result of?

Answer 3

injuries from falling

Question 4

What are the types of syncope?

Answer 4

reflex syncope
orthostatic hypotension syncope
cardiac syncope

Question 5

Describe the pathophysiology of syncope.

Answer 5

reduction in venous blood flow to the heart (non-cardiac)
decreased CO and BP
impaired compensatory reflex response
cerebral hypoperfusion
syncope

Question 6

What are the risk factors for syncope?

Answer 6

family history
age > 70 yrs
previous CV event
emotional distress
medical conditions (CVD, psychiatric disease)
medications (anti-HTN, diuretics, antianginals, antidepressants)

Question 7

Describe the clinical presentation of syncope.

Answer 7

prodromal presentation:
-dizziness, light-headed, fatigue, visual disturbances, nausea, sweating, flushing
syncope:
-loss of postural tone, loss of consciousness
post-syncope attack:
-threat of reoccurrence impairs QoL

Question 8

What can be done to assess for orthostatic hypotension syncope?

Answer 8

measure BP after 5 mins of lying down, then again after 1-3 mins of standing
- > 15 mmHg decrease in SBP or > 7 mmHg decrease in DBP

Question 9

What are the goals of therapy for syncope?

Answer 9

identify causes and eliminate where possible
prevent future recurrences
reduce mortality (cardiac syncope/falls-related)
minimize injury due to falls
avoid AE of therapy

Question 10

What is reflex syncope?

Answer 10

body overreacts to a trigger and cannot compensate for loss of oxygen to brain
-triggers include standing too long, pain, emotional distress
-includes vasovagal syncope

Question 11

Which type of syncope is most common?

Answer 11

reflex syncope

Question 12

How do we treat reflex syncope?

Answer 12

education and reassurance
avoid triggers
recognize prodromal symptoms
learn and practice isometric counter-pressure maneuvers
-crossing/stretching legs, tensing arms
increase fluid and salt intake (volume expansion)

Question 13

What are the pharmacological options for reflex syncope?

Answer 13

midodrine
-alpha1 agonist: increases venous return
beta-blockers
-may be more beneficial in those > 42 yrs old
-can increase risk of orthostatic hypotension
fludricortisone
-use if pts failed addition of salt supplements
paroxetine
-uncommon

Question 14

What is the evidence for medication in treatment of reflex syncope?

Answer 14

clinical trials are lacking or have inconsistent evidence in this area

Question 15

What is orthostatic hypotension syncope?

Answer 15

when moving from lying to sitting or sitting to standing
-may be caused by volume depletion, neurological disorders, or drugs

Question 16

How is orthostatic hypotension syncope treated?

Answer 16

education and reassurance
avoid offending agents
recognize prodromal symptoms
learn and practice isometric counter-pressure maneuvers
sleep with head elevated
measure blood pressure (supine, upright, and sitting)
increase fluid and salt intake

Question 17

What are the pharmacological options for orthostatic hypotension syncope?

Answer 17

midodrine
-alpha1 agonist: increases venous return
fludricortisone
-use if pts failed addition of salt supplements
-fluid volume expansion secondary to Na+ retention
pyridostigmine
-improves standing BP
desmopressin
-useful if nocturnal polyuria
erythropoietin
-useful in anemic pts

Question 18

What is the evidence for medication treatment in orthostatic hypotension syncope?

Answer 18

evidence is lacking for all drug options