As a Cardiology fellow, we get a lot of consults for syncope.
Here is my approach/work-up for this consult.
*Not to use as medical advice, just tips, and always discuss with your fellow/attending*
-thread 🧵-
#MedTwitter #MedEd #Cardiotwitter #IMG
Here is my approach/work-up for this consult.
*Not to use as medical advice, just tips, and always discuss with your fellow/attending*
-thread 🧵-
#MedTwitter #MedEd #Cardiotwitter #IMG
First, what is syncope?:
- It is the sudden and transient loss of consciousness accompanied by postural tone with recovery; bimodal distribution with peak at age 20 and 80
- Due to transient reduction of cerebral blood flow (at least 6-8 seconds) w/ SBP < 60 mm Hg
- It is the sudden and transient loss of consciousness accompanied by postural tone with recovery; bimodal distribution with peak at age 20 and 80
- Due to transient reduction of cerebral blood flow (at least 6-8 seconds) w/ SBP < 60 mm Hg
What are the major causes?:
1) Reflex-Mediated ➡️ Most common (2/3 cases) with exaggerated / inappropriate reflex ➡️ PS tone
2) Dysautonomia ➡️Think Parkinson's, MS, Lewy body dementia, mult-system atrophy
3) Cardiac Syncope ➡️Arrhythmia versus mechanical obstruction
1) Reflex-Mediated ➡️ Most common (2/3 cases) with exaggerated / inappropriate reflex ➡️ PS tone
2) Dysautonomia ➡️Think Parkinson's, MS, Lewy body dementia, mult-system atrophy
3) Cardiac Syncope ➡️Arrhythmia versus mechanical obstruction
Reflex-Mediated Syncope:
- The story is everything! Listen to your patients and they will tell you the answer.
- Common causes include vasovagal (prodromal symptoms), situational (micturition/defecation), carotid sinus, and orthostatic (decrease in SBP ≥ 20 with position)
- The story is everything! Listen to your patients and they will tell you the answer.
- Common causes include vasovagal (prodromal symptoms), situational (micturition/defecation), carotid sinus, and orthostatic (decrease in SBP ≥ 20 with position)
Cardiac Syncope:
- Arrhythmia induced ➡️ look for sick sinus syndrome, AV block, VT, SVT, WPW, prolonged QT, Brugada syndrome
- Mechanical ➡️ With LVOT obstruction (AS, HOCM). Should also consider myocardial ischemia, PE, and cardiac tamponade.
- Arrhythmia induced ➡️ look for sick sinus syndrome, AV block, VT, SVT, WPW, prolonged QT, Brugada syndrome
- Mechanical ➡️ With LVOT obstruction (AS, HOCM). Should also consider myocardial ischemia, PE, and cardiac tamponade.
Work-Up:
- Review vitals, especially orthostatics (ask your RN staff to help, or if possible check yourself)
- Obtain EKG (look for arrhythmias/ischemia)
- Monitor on telemetry
- Obtain a TTE to look for structural heart disease
- Interogate permanent pacemaker
- Review vitals, especially orthostatics (ask your RN staff to help, or if possible check yourself)
- Obtain EKG (look for arrhythmias/ischemia)
- Monitor on telemetry
- Obtain a TTE to look for structural heart disease
- Interogate permanent pacemaker
Further Testing:
- Can consider tilt table for evaluation
- Usually can discharge patients with a Holter Monitor to evaluate for arrhythmias
- Encourage close follow-up with PCP/Cardiology
- Consider other differentials, especially seizure! This is commonly missed.
- Can consider tilt table for evaluation
- Usually can discharge patients with a Holter Monitor to evaluate for arrhythmias
- Encourage close follow-up with PCP/Cardiology
- Consider other differentials, especially seizure! This is commonly missed.
Treatment:
- Reflex-mediated ➡️ Reassurance, avoid triggers, medication adjustment, increase fluids/salts if not contraindicated.
- Orthostatic ➡️ Education about lifestyle changes, encourage compression stockings to reduce venous pooling.
- Reflex-mediated ➡️ Reassurance, avoid triggers, medication adjustment, increase fluids/salts if not contraindicated.
- Orthostatic ➡️ Education about lifestyle changes, encourage compression stockings to reduce venous pooling.
Treatment:
- Cardiac ➡️ Correct electrolytes. If symptomatic bradycardia or AV blocks, would benefit from permanent pacemaker.
- HOCM ➡️ Avoid exertional activities and avoid dehydration (preload dependent)
- Ischemia ➡️ Revascularization if needed to avoid recurrent VT
- Cardiac ➡️ Correct electrolytes. If symptomatic bradycardia or AV blocks, would benefit from permanent pacemaker.
- HOCM ➡️ Avoid exertional activities and avoid dehydration (preload dependent)
- Ischemia ➡️ Revascularization if needed to avoid recurrent VT
Remember, syncope is a common both in clinic and hospital.
Most are reflex-mediated; take time with the history and review their presentation.
Don't forget to think about seizures and discuss with Neurology.
I hope this helps and good luck treating your patients!
Most are reflex-mediated; take time with the history and review their presentation.
Don't forget to think about seizures and discuss with Neurology.
I hope this helps and good luck treating your patients!
Loading suggestions...