Title: Strategic Approach to Syncope for the Office Practitioner
Presenter(s): Dr. Vu Kiet Tran
Date: March 7, 2020
PEARL: Was their syncope aborted ventricular tachycardia?
Aborted sudden cardiac death
PEARL: New differential for syncope:
Fatal: cardiac arrhythmia (and medications), hemorrhage, sepsis/shock
Non-fatal: vasovagal, orthostatic hypotension (and medications), psychogenic
PEARL: Malignant ventricular arrhythmia:
WPW
Long QT syndrome
Short QT syndrome
Brugada syndrome
ARVC
Catecholaminergic VT
PEARL: DDx for Syncope and others:
Syncope and chest pain: aortic dissection, ruptured AAA, STEMI, acute PE
Syncope and headache: SAH, intra-parenchymal hemorrhage
Syncope and shortness of breath: pneumothorax, PE
Syncope and abdo pain: ruptured AAA, ruptured viscous
Syncope and bleeding: UGIB, LGIB
Syncope and rash: anaphylaxis, sepsis
Syncope and nothing else: TIA, stroke (ischemic or hemorrhagic), hypoglycemia
Sepsis mimics: seizures, drop-attacks, conversion syndromes, psychogenic syncope, malingering
PEARL: Syncope is cardiac issue, seizure is neurologic.
PRO TIP: seizure will have post-ictal, drowsy, confused, don't know where they are
PRO TIP: seizure will tend to bite tongue lateral, syncope tends to be anterior
PEARL: Focused complete history for syncope:
HPI: Age >65 yo; associated CP, SOB, palpitations (present: more concerning for cardiac); exertional syncope (present: concerning for cardiac - aortic stenosis, HCOM, AVRC), prodrome (absence - cardiac until proven otherwise, present - maybe vasovagal)
PMHx: CHF, previous syncope episodes, baseline/existing heart disease
FHx: premature sudden death; ARVC, WPW, Brugada, long QT
PsychHx: anything?
Meds: drugs that prolong QT
Ix: abnormal ECG
PEARL: Things to look for on ECG:
Arrhythmias/blockers
Ischemias
PE
Short PR/LGL/WPW
Long QT syndrome
Short QT syndrome
ARVD
Brugada syndrome
HCOM
Pulmonary hypertension
PEARL: Importance of H+P and ECG:
H+P and ECG = 76% diagnostic yield
PEARL: Comments on workup:
ECG: if normal, further cardiovascular testing has little yield
Pregnancy test: women of child-bearing age
D-dimer, myoglobin, CK: not useful
Echo: indicated for structural heart disease or abnormal ECG
Exercise stress testing: indicated for ischemic heart disease, exertional syncope
24 Holter: a negative Holter does not rule out arrhythmogenic etiology
Neurologic testing: indicated for neurologic symptoms/signs +/- seizures +/- carotid bruits
EEG, CT, MRI, carotid bruit: not recommended as routine syncope workup (non-neuro!)
CT head: not indicated unless focal neuro symptoms or seizures
DISCLAIMER: This post contains my interpretation of the presentation. This post is not intended as medical advice. If you have medical concerns, contact a health care provider for assessment. If there are any copyright concerns, please contact me directly to remove the relevant material.
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