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Thread: Cardiovascular Symptoms - Syncope

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    Default Cardiovascular Symptoms - Syncope

    Syncope is a syndrome of sudden, brief loss of consciousness and postural tone with spontaneous, complete recovery resulting from transient global cerebral hypoperfusion. Seizures, metabolic disturbances (e.g., hypoglycemia), and concussion must be distinguished from syncope and do not result from temporary global cerebral hypoperfusion.

    Etiology

    Most patients with a simple fainting spell, or vasovagal syncope, do not seek medical attention. Etiologies of syncope vary depending on the clinical setting, study population, definition of syncope, and rigor of the diagnostic evaluation. In general, syncope is classified into the following major categories:

    • Reflex (neurally) mediated syncope
    • Orthostatic hypotension
    • Cerebrovascular disease (a rare cause of syncope)
    • Medication-induced syncope
    • Cardiac syncope (due to organic heart disease and arrhythmias)
    • Syncope due to an unknown cause


    Differential Diagnosis
    Cardiovascular Symptoms - Syncope-screen-shot-2016-11-08-at-12-56-26-pm-png

    Open-ended Questions
    Cardiovascular Symptoms - Syncope-screen-shot-2016-11-08-at-2-24-41-pm-png

    Interview Framework
    • Determine whether the patient experienced true syncope (abrupt loss of consciousness, loss of postural reflexes, and spontaneous and complete return to consciousness without intervention) rather than another type of "dizziness" or seizure.
    • If the episode was observed, interview the witness(es).
    • Determine the circumstances surrounding the episode, such as body position (standing, sitting, or supine), activity, and environment.
    • Determine whether there were any premonitory symptoms before the loss of consciousness (especially important for vasovagal syncope).
    • Determine features common to all episodes.
    • Assess for alarm symptoms (see below).
    • Determine whether there is underlying heart disease (confers a worse prognosis)
    • Classify syncope into one of the following subtypes:
      • Reflex-mediated syncope, which is suggested by the following: 1)absence of cardiac disease or family history of sudden death; 2)previous history of syncope or family history of syncope (a parental history of fainting increases the relative probability of fainting in offspring, particular if both parents are affected); 3)occurs after pain or sudden unexpected sight (e.g., blood), smell, or sound; 4)prolonged standing in a close, hot environment; 5)"graying out", loss of hearing, nausea, or vomiting; 6)occurs during or after eating; 7)occurs after exertion; and 8)occurs with pressure on carotid sinus (e.g., tight collar, shaving, tumor) or head turning.
      • Orthostatic hypotension, which is suggested by the following: 1)occurs after standing up; 2)recent start or change in medication or alcohol use; 3)volume loss; 4)prolonged standing in a close, hot environment; 5)history of parkinsonism or autonomic neuropathy; and 6)occurs after exertion or with weight lifting or brass instrument use.
      • Cerebrovascular, which is suggested by the following: 1)occurrence with arm exercise; 2)blood pressure or pulse difference between the right and left arm; 3)known subclavian steal syndrome; 4)focal neurologic features suggestive of vertebrobasilar transient ischemic attack; or 5)history of migraine.
      • Medication-induced, which is suggested by the following: history of a new or increased dose of a vasoactive medication associated with orthostatic hypotension, diuretics, or antiarrhythmic agents.
      • Cardiac syncope, which is suggested by the following: 1)a family history of sudden death or heart disease; 2)history of organic heart disease; 3)history of palpitations or arrhythmias; 4)syncope in the supine position; and 5)syncope during exercise.



    Alarm Symptoms
    Cardiovascular Symptoms - Syncope-screen-shot-2016-11-08-at-12-58-29-pm-png
    Cardiovascular Symptoms - Syncope-screen-shot-2016-11-08-at-12-58-40-pm-png

    Focus-ended Questions
    Cardiovascular Symptoms - Syncope-screen-shot-2016-11-08-at-3-07-50-pm-png
    Cardiovascular Symptoms - Syncope-screen-shot-2016-11-08-at-3-08-03-pm-png
    Last edited by admin; Tue 8th November '16 at 3:14pm.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease. Chengdu, Sichuan, China.

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  2. #2
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    Default Re: Cardiovascular Symptoms - Syncope

    Diagnostic Approach

    Initial Diagnostic Approach
    Cardiovascular Symptoms - Syncope-screen-shot-2016-11-08-at-1-00-27-pm-png

    Advanced Diagnostic Approach
    Cardiovascular Symptoms - Syncope-screen-shot-2016-11-08-at-3-28-24-pm-png
    Last edited by admin; Tue 8th November '16 at 3:34pm.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease. Chengdu, Sichuan, China.

    Blog: http://www.tomhsiung.com
    Facebook: http://www.facebook.com/TomHsiung
    Twitter: @TomHsiung
    Sina Microblog (Weibo): http://weibo.com/xiongliang0



  3. #3
    PharmD Year 1 TomHsiung's Avatar
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    Default Re: Cardiovascular Symptoms - Syncope

    The differential diagnosis for dizziness is extensive, encompassing diseases of the inner ear, central and peripheral nervous system, cardiovascular system and psychiatric disease. Fortunately, an organized approach greatly simplifies evaluating the dizzy patient. The first step recognizes that most patients who complain of dizziness are actually complaining of 1 of 4 distinct symptoms: vertigo, near syncope, disequilibrium, and ill-defined lightheadedness. Each of these symptoms has its own particular differential diagnosis and evaluation.

    Differential Diagnosis of Dizziness
    • Vertigo is the most common cause of dizziness. Vertigo arises from diseases of the inner ear (peripheral) or diseases of brainstem (central). Central vertigo is less common than peripheral (~= 10% vs. 90%) but far more serious.
      • Peripheral
        • Benign paroxysmal positional vertigo (BPPV)
        • Labyrinthitis or vestibular neuritis
        • Meniere disease
        • Uncommon etiologies: head trauma, herpes zoster

      • Central
        • Cerebrovascular disease
          • Vertebrobasilar insufficiency (VBI)
          • Cerebellar or brainstem stroke
          • Cerebellar hemorrhage
          • Vertebral artery dissection (VAD)
          • Brainstem aneurysm

        • Cerebellar degeneraton
        • Migraine
        • Multiple sclerosis (MS)
        • Alcohol intoxication
        • Phenytoin toxicity
        • Inhalant abuse
        • Tumors of the brainstem or cerebellum

    • Near syncope is a common cause of severe dizziness, particularly in the elderly. It can be caused by a variety of life-threatening diseases.
    • Dysequilibrium
      • Multiple sensory deficits
      • Parkinson disease
      • Normal-pressure hydrocephalus
      • Cerebellar disease (degeneration, tumor, infarction)
      • Peripheral neuropathy (i.e., diabetes)
      • Dorsal column lesions
        • B12 deficiency
        • Syphilis
        • Compressive lesions

      • Drugs (alcohol, benzodiazepines, anticonvulsants, ahminoglycosides, antihypertensives, muscle relaxants, cisplatin)

    • Nonspecific dizziness
      • Psychological
        • Major depression
        • Anxiety, panic disorder
        • Somatization disorder


    The first pivotal step in evaluating the dizzy patient is to clarify which symptom the patient is experiencing, since this limits the differential diagnosis and focuses the evaluation on the appropriate set of diagnostic possibilities for that particular symptom. Therefore, the first and most important pivotal question is "What does it feel like when you are dizzy?" At this point, patients must be given enough time, without interruptions or suggestions, to describe their dizziness as clearly as possible.

    Cardiovascular Symptoms - Syncope-screen-shot-2017-04-11-at-7-40-58-pm-png

    In practice, many patients often have difficulty describing their symptom and have ill-defined lightheadedness. Therefore, the second pivotal step in those patients is to search for neurologic and cardiovascular clues (signs and symptoms) that point to the involved system.

    Cardiovascular Symptoms - Syncope-screen-shot-2017-04-11-at-7-51-31-pm-png
    Last edited by TomHsiung; Tue 11th April '17 at 9:11pm.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease.

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