Transcript Common Cardiac Complaints in College Students

Common Cardiac Complaints
in College Students
Victoria E Judd MD, FACC
University of Utah
Disclaimer
• Psychogenic causes of common cardiac
complaints will not be discussed in this
presentation.
• However, psychogenic causes should be
considered if evaluation does not
demonstrate an organic cause.
Chest Pain
Definition, etc.
• A pain or uncomfortable sensation in the
chest
• One of the three cardinal signs of heart
disease. The other two being; dyspnea
and palpitations.
• One of the most common challenges for
the practitioner.
Chest Pain
Case
• A 26 year old man presents with
intermittent, sharp, mid-sternal chest pain.
The pain is somewhat worse with
inspiration and is associated with mild
dyspnea . Several weeks ago , he had
“cold” symptoms .
Chest Pain
Goals
• Determine the diagnosis
• Implement the immediate management
plan
• Implement the long term management
plan
Chest Pain
Is the chest pain due to an acute , potentially
life threatening condition that mandates
immediate hospitalization and aggressive
evaluation?
• Acute Ischemic Heart Disease
• Aortic Dissection
• Pulmonary Embolism
• Spontaneous Pneumothorax
Chest Pain
Is the chest pain due to a chronic condition
that may lead to a serious complication ?
• Stable Angina
• Aortic Stenosis
• Pulmonary Hypertension
Chest Pain
Is the chest pain due to an acute condition
that mandates specific treatment ?
• Pericarditis
• Pneumonia/Pleuritis
• Herpes Zoster
Chest Pain
Is the chest pain due to a treatable chronic
condition?
• Esophageal Reflux or Spasm
• Peptic Ulcer Disease
• Gallbladder Disease
• Other Gastrointestinal Conditions
• Musculoskeletal Disease
• Anxiety
Causes of nonemergent chest pain in
MIRNET primary care practices
• A prospective study of 399 episodes
of chest pain in patients seen in
multiple outpatient centers over a
one-year period noted the following
prevalence of various causes of chest
pain:
Causes of nonemergent chest pain in
MIRNET primary care practices
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Cause
Prevalence, percent
Musculoskeletal, including
36
costochondritis
Gastrointestinal
19
Cardiac
16*
Stable angina
10.5
Unstable angina or MI
1.5
Other cardiac
3.8
Psychiatric
8
Pulmonary
5
Other/unknown
16
Causes of nonemergent chest pain in
MIRNET primary care practices
• Approximately 60 percent of chest pain
diagnoses were not "organic" in origin
(i.e., not due to cardiac, gastrointestinal,
or pulmonary disease).
• Musculoskeletal chest pain accounted for
36 percent of all diagnoses (of which
costochondritis accounted for 13 percent)
followed by reflux esophagitis (13
percent).
Causes of nonemergent chest pain in
MIRNET primary care practices
• Stable angina pectoris was
responsible for 11 percent of chest
pain episodes; unstable angina or
myocardial infarction occurred in
only 1.5 percent.
• Nevertheless, most of the ancillary
diagnostic testing used was directed
toward finding or excluding a cause
of coronary disease.
Causes of nonemergent chest pain in
MIRNET primary care practices
• MIRNET: Michigan Research Network.
* As high as 50 percent in older populations.
Adapted from Klinkman, MS, Stevens, D,
Gorenflo, DW, J Fam Pract 1994; 38:345.
Chest Pain
• The presence of risk factors and the age of
the patient population are important
contributors to coronary artery disease
(CHD) prevalence.
• In one retrospective review, as an
example, only 7 percent of patients less
than age 35 who had chest pain were
diagnosed with CHD.
• In contrast, the incidence of cardiac
diagnoses may exceed 50 percent in
patients with chest pain after the age of
40.
Chest Pain
• One study found that physicians were able
to correctly diagnose a nonorganic (i.e.,
not due to cardiac, gastrointestinal, or
pulmonary disease) versus organic cause
of chest pain in 88 percent of patients
using only the history and physical
examination.
• In the remaining 12 percent who were
misdiagnosed as having chest pain of
organic etiology, most of the diagnoses
were made with little confidence.
Chest Pain
History
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O: Onset
L: Length, Location
D: Duration
C: Compounding factors-alleviating or
aggravating
• A: Associated Symptoms
• R: Radiation
• S: Severity, quality
Chest Pain History
• One study of patients presenting to
the emergency department with
chest pain found that "sharp" or
"stabbing" was a low-risk description
only if the pain had a pleuritic or
positional component, was fully
reproducible by palpation, and the
patient had no history of angina or
myocardial infarction.
Chest Pain History
• No patients who presented with these
findings had a cardiac etiology of pain.
• However, all three of these characteristics
were present in only 48 of 596 patients
studied.
• It is important to clarify with patients who
use the word "sharp" that they actually
mean "knife-like" or "stabbing" rather
than "severe".
Chest Pain History
• Ischemic pain is a diffuse discomfort
that may be difficult to localize. Pain
that localizes to a small area on the
chest is more likely of chest wall or
pleural origin rather than visceral.
Chest Pain History
Descriptions decreasing the
likelihood of MI
• Pleuritic
• Positional
• Sharp
• Reproducible with palpation
• Inframammary location
• Nonexertional
Chest Pain History
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Descriptions increasing the likelihood of MI
Radiation to right arm or shoulder
Radiation to both arms or shoulders
Exertional
Radiation to left arm
Associated with diaphoresis
Associated with nausea or vomiting
Worse than previous angina or similar to
previous MI
Described as pressure
Nontraditional risk factors for myocardial
infarction in younger adults*
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Risk factor
Physical stress with MI
Obesity alone
Sympathomimetic drug use
Estrogen or oral contraceptive pill use
Valvular heart disease
Collagen vascular disease
Cardiomyopathy
History chest irradiation
Myocarditis
Chronic dysrhythmia
Sickle cell anemia
Coronary artery spasm
Percent
39
30
7
6
3
2
2
1
1
1
<1
6.5
Nontraditional risk factors for myocardial
infarction in younger adults*
• * 209 young adults, 98 percent of whom also had
traditional coronary risk factors. Data from
Kanitz, MG, Givannucci, SJ, Jones, JS, Mott, M, J
Emerg Med 1996; 14:139.
Occurrence of myocardial infarction (MI) in 277
patients with documented spasm. Data from Bory
M, Pierron F, Panagides D, Bonnet JL, et al, Eur
Heart J 1996; 17:1015.
Chest Pain
History
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Exertional or non-exertional
Cardiac Risk Factors
Previous Cardiac History
Previous GI History
Previous Pulmonary History
Recent Prolonged Immobility
Drugs; cocaine, methamphetamines
Chest Pain
Physical Exam
• Blood pressure in Both Arms
• Pulses in both legs
• Chest auscultation –decreased breath
sounds , pleural rub, evidence of
pneumothorax, pulmonary embolus,
pneumonia, pleurisy.
• Cardiac exam should include second heat
sound , rub, third or fourth heart sound ,
murmurs
Case 1
• A 26 year old man presents with
intermittent, sharp, mid-sternal chest pain.
The pain is somewhat worse with
inspiration and is associated with mild
dyspnea . Several weeks ago , he had
“cold” symptoms .
Chest Pain
Case 1
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General no acute distress
Weight 160 pounds, height 72 inches
Heart rate 110 bpm ( beats per minute)
Respiratory rate 20
Blood Pressure 124/70 in both arms
Chest Pain
Case
• No JVD, carotids equal/brisk upstrokes, no
bruits
• Normal lung exam
• Pericardial friction rub present
Chest Pain
Case
• Abdomen soft/non-tender, no
organomegaly, no abnormal pulsations or
bruits
• No cyanosis, clubbing, or edema
• Peripheral pulses equal (U/L extremities)
Chest Pain
Labs
What labs do you want to order ?
• Chest X-ray
• ECG (Electrocardiogram )
• Cardiac Enzymes: Troponin or CPK
• Computed Tomography (CT)
• MRI
• Echocardiogram
Chest Pain Case 2
• A 19 year old student presents with chest
pain that is worse when laying down and
wakes her up at night.
• It is not related to eating or activity.
• It is pleuritic. It is better when she sits up.
• Her physical exam is normal.
• Most likely diagnosis is?
Chest Pain
Differential Diagnosis
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Angina
Myocardial Infarction
Aortic Stenosis
Aortic Dissection
Pericarditis
Pulmonary Hypertension
Pulmonary Embolism
Pneumonia
Chest Pain
Differential Diagnosis
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Spontaneous Pneumothorax
Esophageal Rupture
Gastroesophageal Reflux
Esophageal Spasm
Musculoskeletal Pain
Herpes Zoster
Anxiety
Chest Pain Case 3
• A 24 year old graduate student presents to
clinic with the complaint of chest pain.
• It is pleuritic.
• It located over the left chest.
• It is worse with anxiety.
• Pressing on the chest makes it better.
• The physical exam is normal.
• What is the chest pain due to?
Dyspnea
Definition , etc.
• An abnormally uncomfortable awareness
of breathing
• As with all disease individual perceptions,
general physical condition , school history,
work history, recreational habits are
important
Dyspnea
Case
• A 22 year old obese man presents to
student health with dyspnea . He reports
that the dyspnea began suddenly when he
was sitting in class. He notes associated
left lateral chest pain that is worse when
he breathes deep. He denies fever, chills,
or cough.
Dyspnea
Case
• He appears to be in moderate respiratory
distress.
• BP 110/70 mm Hg
• Heart Rate (HR) 104 bpm regular
• Respiratory Rate (RR) 28/minute
• Oxygen saturation 93 % on room air
• Height 72 inches
• Weight 264 pounds
Dyspnea
Cardiac Causes of
• Valvular heart disease (mitral or aortic
regurgitation or stenosis)
• Left ventricular systolic dysfunction
(Cardiomyopathy= CM)
• Left ventricular diastolic dysfunction
• Pericardial disease
• Ischemia
• Restrictive heart disease (Hypertrophic
Obstructive CM= HOCM)
Dyspnea
Pulmonary Causes of
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Pneumonia
Asthma
Pulmonary embolus
Pneumothorax
Pulmonary fibrosis
Pulmonary hypertension
Pleural Effusion
Chronic obstructive pulmonary disease
Dyspnea
Other Causes of
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Anemia
Hyperthyroidism
Obesity
Neurological disease
Physical de-conditioning
Anxiety
Dyspnea Questionnaire
• Please select up to three phrases
that best describe your breathing
discomfort. If you choose more than
one phrase, please also note the
phrase that most closely describes
the sensation you feel. If none of
these phrases applies, please write in
your own description of your
breathing discomfort.
Dyspnea Questionnaire
• My breathing is shallow.
• I feel an urge to breathe more.
• My chest is constricted.
• My breathing requires effort.
• I feel a hunger for more air.
• I feel out of breath.
• I cannot get enough air.
Dyspnea Questionnaire
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My breath does not go in all the way.
My chest feels tight.
My breathing requires work.
I feel that I am smothering/suffocating.
I feel that I cannot get a deep breath.
I feel that I am breathing more.
My breath does not go out all the way.
My breathing is heavy.
Dyspnea
History
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Onset ; sudden or gradual
Chest Pain (CAD, PE, Pneumothorax)
Cough (Pneumonia, Asthma, Bronchitis)
Fever (Pneumonia, Bronchitis)
Hemoptysis (PE, Bronchitis)
History of smoking (COPD)
Cardiac risk factors (Angina, MI)
Chest wall trauma (Pneumothorax)
Dyspnea
History
• Frequently precipitated by exertion ,
regardless of cause
• Occurs at rest; indicates cardiac or
pulmonary disease
• Occurs 2 to 4 hours after falling asleep –
paroxysmal nocturnal dyspnea
Dyspnea History
• Chest tightness or constriction
- Bronchochonstriction, interstitial
edema
= Asthma or
Myocardial ischemia
Dyspnea
• Increased work or effort of breathing
- Airways obstruction, neuromuscular
disease, reduced chest wall or
pulmonary compliance
=COPD, moderate to severe asthma,
myopathy, pulmonary fibrosis
Dyspnea
• Air hunger, need to breathe, urge to
breathe
- Increased drive to breathe
=CHF, pulmonary embolism, moderate
to severe asthma or COPD
Dyspnea
• Rapid, shallow breathing
- Reduced chest wall or pulmonary
compliance
=Interstitial fibrosis
Dyspnea
• Suffocating, smothering
- Alveolar edema
= Pulmonary edema
Dyspnea
• Heavy breathing, breathing more
- Inadequate oxygen delivery to the
muscles
= Deconditioning
Case
• A 22 year old obese man presents to
student health with dyspnea . He reports
that the dyspnea began suddenly when he
was sitting in class. He notes associated
left lateral chest pain that is worse when
he breathes deep. He denies fever, chills,
or cough.
Dyspnea
Case
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No Jugular Venous Distension
Chest is clear
Normal cardiac exam
No peripheral edema
No calf tenderness
Dyspnea
Physical Exam
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Tachypnea
Cyanosis
Evidence of congestive heart failure
Evidence of valvular heart disease
Evidence of lung disease
Wheezing may be heart with heart failure
or lung disease
Dyspnea
Diagnostic Evaluation
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Chest X-Ray
Complete Blood Count; anemia
Pulmonary Function Tests
ECG
Echocardiogram
Serum brain natriuretic peptide (BNP)
http://wwwmedlib.med.utah.edu/kw/ecg/index.
html
Dyspnea
Differential Diagnosis
Cardiac
• Congestive Heart Failure
• Ischemia
• Valvular Heart Disease
• Pericardial ( Tamponade, Constriction)
• Restrictive Heart Disease ( Infiltrative or
Hypertrophic Heart Disease)
Dyspnea
Differential Diagnosis
Pulmonary
• COPD
• Asthma
• Pneumonia
• Pleural Effusion
• Pulmonary Embolism
• Pneumothorax
• Pulmonary Fibrosis
• Pulmonary Hypertension
• Airway Obstruction
Dyspnea
Differential Diagnosis
Other
• Anemia
• Hyperthyroidism
• Diaphragmatic Paralysis
Case
• ? Cause
• Dyspena without other findings =
Pulmonary embolus until proven otherwise
Palpitations
Definition, etc.
• The subjective awareness of the heart
beating
• The most common causes are benign.
Causes of Palpitations
Cardiac
• Any arrhythmia
• Cardiac and extracardiac shunts
• Valvular heart disease
• Pacemaker
• Atrial myxoma
• Cardiomyopathy
Causes of Palpitations
Psychiatric disease
• Panic attack and disorder
• Generalized anxiety disorder
• Somatization
• Depression
Causes of Palpitations
Medications
• Sympathomimetic agents
• Vasodilators
• Anticholinergic drugs
• Beta blocker withdrawal
Causes of Palpitations
Habits
• Cocaine
• Amphetamines
• Caffeine
• Nicotine
Causes of Palpitations
Metabolic disorders
• Hypoglycemia
• Thyrotoxicosis
• Pheochromocytoma
• Mastocytosis
Causes of Palpitations
High output states
• Anemia
• Pregnancy
• Paget's disease
• Fever
Causes of Palpitations
Catecholamine excess
• Stress
• Exercise
--Data from Weber, BE, Kapoor, WN, Am J Med
1996; 100:138.
Causes of Palpitations
• In a study of 190 patients presenting with
a chief complaint of palpitations to a
university medical center, an etiology was
determined in 84 percent.
• The cause was cardiac in 43 percent,
psychiatric in 31 percent, and
miscellaneous (e.g., medication-induced,
thyrotoxicosis, caffeine, cocaine, anemia,
amphetamine, mastocytosis) in 10
percent.
Causes of Palpitations
• A cardiac etiology was more common in
patients presenting to the emergency
department than to the medical clinic (47
versus 21 percent), while psychiatric
etiologies were more common in the
medical clinic (45 versus 27 percent).
• Cardiac etiologies may also be more
common among patients who present to a
specialist.
Causes of Palpitations
In the university study cited above,
four variables were independent
predictors of a cardiac etiology of
palpitations:
• Male sex
• Description of an irregular heart beat
• History of heart disease
• Event duration >5 minutes
Causes of Palpitations
• None of the patients with zero
predictors had a cardiac etiology,
compared with 26, 48, and 71
percent of patients with 1, 2, and 3
predictors, respectively.
• Evaluation and outcomes of patients with
palpitations. Weber BE; Kapoor WN. Am J Med
1996 Feb;100(2):138-48.
Palpitations
Case
• A 22 year old female presents with six
month history of intermittent palpitations.
This occurs almost daily at rest , lasting 5
minutes at a time .There is no associated
dizziness, chest pain , shortness of breath.
No previous history of heart disease. She
drinks several cups of coffee a day .
Palpitations
Case Additional Questions
• Have patient demonstrate rate and rhythm
by tapping hand
• She denies cocaine or methamphetamine
use
• Functionally asymptomatic between
episodes
• No family history of syncope or sudden
death
• Feels better when she is jogging
Palpitations
Case
• Physical exam is normal
What test should she get ?
• ECG(WPW, HOCM)
• 24 hours holter monitor
• Event monitor (best way to make the
diagnosis)
• Echocardiogram
• Reassurance
Prolonged QT interval
The corrected QT interval (QTc) is calculated by dividing the QT
interval (0.60 seconds) by the square root of the RR interval
(0.84 seconds). In this case, the QTc is 0.65 seconds.
Palpitations Case
• Often a patient notes an intermittent
pounding sensation while lying in bed,
particularly in the supine or left lateral
decubitus position.
• This symptom is commonly the result of
supraventricular or ventricular premature
beats, which occur more frequently at
slow heart rates, as when a person is
resting in bed.
• In the left lateral decubitus position, the
apex of the heart is closer to the chest
wall, which may account for the greater
awareness of palpitations in this position.
Palpitations
History
• Regular rhythm suggests SVT or VT
• Abrupt onset and offset suggests SVT or
VT
• Associated syncope suggests VT
• Missed beats are usually PAC or PVC
• Is it exercise induced ?
• Make sure it is not a pro-arrhythmic effect
of the patients medications
Palpitations
Physical Exam Clues
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Murmurs
Gallop Rhythms
Elevated jugular pressure
Rales
Enlarged thyroid gland
Palpitations
Further diagnostic testing for three groups
of patients:
• Those in whom the initial diagnostic
evaluation (history, physical examination,
and electrocardiogram) suggests an
arrhythmic cause.
• Testing is particularly important in patients
who experience syncope or presyncope in
association with palpitations.
Palpitations 2
• Those who are at high risk for an
arrhythmia.
• Patients are considered at high risk if they
have organic heart disease or any
myocardial abnormality that can lead to
serious arrhythmias, including scar
formation from myocardial infarction,
idiopathic dilated cardiomyopathy,
clinically significant valvular regurgitant or
stenotic lesions, and hypertrophic
cardiomyopathy.
Palpitations 2
• These disorders have all been shown to be
associated with the development of
ventricular tachycardia.
• Other high-risk patients are those with a
family history of arrhythmia, syncope, or
sudden death from cardiac causes, such
as from a cardiomyopathy or the long QT
syndrome.
• Low-risk patients are those without a
potential substrate for arrhythmias.
Palpitations 3
• Those who remain anxious to have a
specific explanation for their
symptoms.
Palpitations
• If there is no evidence of heart
disease and the palpitations are
unsustained and well tolerated,
ambulatory monitoring or
reassurance is recommended.
• Two weeks of transtelephonic
monitoring is the optimal ambulatory
monitoring technique in most cases.
Palpitations
• If the initial evaluation suggests
heart disease and the palpitations
are unsustained, ambulatory
monitoring is again recommended.
Palpitations
• Regardless of the presence or
absence of heart disease, if the
palpitations are sustained or poorly
tolerated, referral to a cardiologist is
recommended.
“Syncope and sudden death are the same, except
that in one you wake up”
- Anonymous
Syncope
• Syncope is most often benign and
self-limited.
• Injuries associated with syncopal
attacks occur in about one-third of
patients, and recurrent episodes can
be psychologically devastating.
• Syncope can be a premonitory sign
of cardiac arrest, especially in
patients with organic heart disease.
Syncope
Definition, etc.
• A transient loss of consciousness due to
reduced cerebral blood flow
• It is a common clinical entity accounting
for 3 % of all emergency room visits and
6% of all hospital admissions in adult
patients.
SYNCOPE: Natural
History
Mortality
%
Sudden Death
60
50
40
30
20
10
0
1
2
3
4
5
0
1
2
3
4
5
Year of follow-up
Cardiogenic
Undetermined
Noncardiac
Kapoor: Medicine, 1990
Syncope
Natural History
• Recurrent, unexplained syncope ,
particularly in someone with structural
heart disease is associated with a high risk
for death ( 40 % mortality within 2 years).
Syncope
• Neurally mediated (e.g., vasovagal) — 58
percent
• Cardiac disease, most often a
bradyarrhythmia or tachyarrhythmia — 23
percent
• Neurologic or psychiatric disease — 1
percent
• Unexplained syncope — 18 percent; a
higher value (41 percent) was noted in
another large series
Neurally-mediated (reflex)
Syncope
Vasovagal syncope (common faint)
• - Classical
• - Non-classical
Carotid sinus syncope
Glossopharyngeal neuralgia
Neurally-mediated (reflex)
Syncope
• Situational syncope
- Acute hemorrhage
- Cough, sneeze
- Gastrointestinal stimulation (swallow,
defecation, visceral pain)
- Micturition (post-micturition)
- Post-exercise
- Post-prandial
- Others (e.g., brass instrument playing,
weightlifting)
- Hair combing
Orthostatic Hypotension
• Autonomic failure
• - Primary autonomic failure syndromes (e.g.,
pure autonomic failure, multiple system atrophy,
Parkinson's disease with autonomic failure)
• - Secondary autonomic failure syndromes (e.g.,
diabetic neuropathy, amyloid neuropathy)
• - Post-exercise
• - Post-prandial
• Drug (and alcohol)-induced orthostatic syncope
• Volume depletion
• - Hemorrhage, diarrhea, Addison's disease
Cardiac arrhythmias as primary
cause
• Sinus node dysfunction (including
bradycardia/tachycardia syndrome)
• Atrioventricular conduction system disease
• Paroxysmal supraventricular and
ventricular tachycardias
• Inherited syndromes (e.g., long QT
syndrome, Brugada syndrome)
• Implanted device (pacemaker, ICD)
malfunction
• Drug-induced proarrhythmias
Structural cardiac or
cardiopulmonary disease
• Cardiac valvular disease
• Acute myocardial infarction/ischemia
• Obstructive cardiomyopathy
• Atrial myxoma
• Acute aortic dissection
• Pericardial disease/tamponade
• Pulmonary embolus/pulmonary
hypertension
Cerebrovascular
• Vascular steal syndromes
Brignole, M, Alboni, P, Benditt, DG, et al.
Guidelines on management (diagnosis and
treatment) of syncope-update 2004. Europace
2004; 6:467. Copyright ©2004 Oxford University
Press.
Syncope
History
• The history is the most important aspect of
evaluating a patient with syncope and
frequently gives clues to its underlying
cause.
• Obtain the history from the patient and any
witnesses
Syncope
History
• What was the patient doing at the time of
the syncopal episode?
• What symptoms occurred before the
event?
• Is the patient on any medications?
• Was there any seizure activity?
• How long was the patient unconscious?
Syncope
History
• When the patient came to were they
confused or drowsy ? (neurological)
• Cardiac syncope is always sudden in
onset, may be preceded by palpitations or
chest pain , may occur with exertion , may
occur without a warning , and usually
resolves spontaneously
• Is there a family history of syncope?
Neurally-mediated syncope
• Absence of cardiological disease
• Long history of syncope
• After sudden unexpected unpleasant sight,
sound, smell or pain
• Prolonged standing or crowded, hot places
• Nausea, vomiting associated with syncope
• During the meal or in the absorptive state
after a meal
• With head rotation, pressure on carotid
sinus (as in tumors, shaving, tight collars)
• After exertion
Neurally-mediated Syncope
• In one study, the most specific
predictors of neurally mediated
syncope were more than four years
between the first and last episode of
syncope, abdominal discomfort
before loss of consciousness, and
nausea and diaphoresis during the
recovery phase.
Syncope due to orthostatic
hypotension
• After standing up
• Temporal relationship with start of
medication leading to hypotension or
changes of dosage
• Prolonged standing especially in
crowded, hot places
• Presence of autonomic neuropathy or
Parkinson's
• After exertion
Cardiac syncope
• Presence of definite structural heart
disease
• During exertion, or supine
• Preceded by palpitation
• Family history of sudden death
Number of episodes
• Benign causes of syncope are associated
with a single syncopal episode in most
patients, but some have multiple episodes
over many years.
• By comparison, the patient with multiple
episodes occurring over a short period of
time is more likely to suffer from a serious
underlying disorder.
Prodrome
• "Auras" are associated with seizures.
• In comparison, neurocardiogenic
syncope (also called vasovagal
syncope) is usually, but not always,
associated with a prodrome of
nausea, warmth, pallor,
lightheadedness, and/or diaphoresis.
• Such symptoms may also occur
without an episode of syncope.
Sudden Onset
• The sudden loss of consciousness without
warning is most likely to result from an
arrhythmia (bradycardia or tachycardia).
• In one study of 85 patients who had an
implantable loop recorder to evaluate
syncope, an arrhythmia was present in 64
percent of sudden syncopal events.
• In contrast, presyncope (lightheadedness,
dizziness, vertigo, unsteadiness) was a
nonspecific symptom that was associated
with sinus rhythm in 75 percent of
episodes.
Position
• Neurocardiogenic syncope commonly
occurs when the patient is erect, not
usually when supine.
• Syncope resulting from orthostatic
hypotension is frequently associated with
the change from a supine to erect posture.
• Syncope that occurs when the patient is
supine suggests an arrhythmia.
Duration of Symptoms
• A prolonged loss of consciousness
may indicate a seizure.
• By comparison, arrhythmias and
neurocardiogenic syncope are often
associated with a brief period of
syncope, since the supine position
reestablishes some blood flow to the
brain and can therefore result in the
restoration of consciousness.
Duration of Symptoms
• Persistence of nausea, pallor, and
diaphoresis in addition to a prolonged
recovery from the episode suggest a vagal
event.
• These findings are helpful in distinguishing
neurocardiogenic syncope from syncope
due to an arrhythmia.
• Significant neurologic changes or
confusion during the recovery period may
be due to a stroke or seizure.
Exertional Syncope
• An evaluation to rule out potentially lifethreatening causes for syncope is required
if syncope occurs during exertion.
• Among the pathologic causes of exertional
syncope are ventricular tachycardia and
obstruction resulting from aortic stenosis
or hypertrophic cardiomyopathy, and
hypotension due to vagally-mediated
vasodepression in patients with
hypertrophic cardiomyopathy.
Distinction of syncope
from seizures
• Seizures are the probable cause of 5 to 15
percent of apparent syncopal episodes.
• They can mimic syncope when the seizure
is atypical and not associated with tonicclonic movements, the seizure is not
observed, or a complete history cannot be
obtained.
• In addition, some patients with syncope
present with myoclonic or other
involuntary movements that are
suggestive of a seizure but are actually
due to cerebral hypoxia.
Distinction of syncope from
seizures
• One distinguishing feature is that
patients with seizures rarely have a
rapid and complete recovery.
• Instead, the postictal state is
characterized by a slow and
complete recovery.
Physical Exam Blood Pressure
• Blood pressure obtained in the supine,
sitting, and erect position may detect
orthostatic hypotension.
• The 2004 ESC syncope guidelines
recommended orthostatic blood pressure
measurement with the patient standing
after five minutes of lying supine.
• Blood pressure should be measured each
minute (or more often) in the standing
position for three minutes or more (or as
long as the patient tolerates) until the
blood pressure nadir is reached.
Physical Exam Blood Pressure
• Orthostatic hypotension was defined
as a decrease in systolic blood
pressure of ≥20 mmHg or a decrease
of systolic blood pressure to <90
mmHg, regardless of whether
symptoms occur. Other criteria for
orthostatic hypotension included a
≥10 mmHg fall in diastolic pressure
and symptoms of cerebral
hypoperfusion.
When to refer a patient with
syncope
For diagnosis
• Suspected or known significant heart
disease
• Those ECG abnormalities suspected
of arrhythmic syncope
• Syncope occurring during exercise
• Syncope causing severe injury
• Family history of sudden death
When to refer a patient with
syncope
For diagnosis
• Other categories that occasionally may
need to be admitted:
• - Patients without heart disease but with
sudden onset of palpitations shortly before
syncope, syncope in the supine position
and patients with frequent recurrent
episodes
• - Patients with minimal or mild heart
disease when there is high suspicion of
cardiac syncope
When to refer a patient with
syncope
For treatment
• Cardiac arrhythmias as cause of
syncope
• Syncope due to cardiac ischemia
• Syncope secondary to the structural
cardiac or cardiopulmonary diseases
• Cardioinhibitory neurally-mediated
syncope when pacemaker
implantation is planned
Syncope
Case
• A 25 year old woman presents to student
health after “passing out “ while standing
in line at the book store . Immediately
before passing out , she recalls she felt
nauseated and warm all over . She then
got light headed and passed out . She was
out for less than a minute . When she
woke up she was oriented . She was not
incontinent nor postictal .
Syncope
Case
• This has not happened before . A witness
said she tried to hold onto the counter
before she collapsed .
Syncope
Case
• Her heart rate and blood pressure are
normal
• Her pulmonary, cardiac, and neurological
examination are all normal
Syncope
Physical Exam
• Are there orthostatic changes in blood
pressure, heart rate?
• The cardiac and neurological exams are
the most important to concentrate on
• Carotid sinus massage should generally
be avoided
Syncope
Case; Tests
What test should be done?
• Hematocrit
• Electrolytes, glucose
• Pregnancy test
• ECG
• Echocardiogram
• 24 hour holter monitoring
• Event monitor
• Electrophysiological testing
Syncope
Case; Tests
• Head CT scan
• EEG
• Tilt table testing
Tilt Table
• The upright tilt table test is
commonly performed for the
evaluation of syncope, although the
test has limited specificity,
sensitivity, and reproducibility.
Neurological Testing
• Neurologic tests, including
electroencephalogram (EEG), brain CT
scan, brain magnetic resonance imaging,
and carotid Doppler ultrasound, are
frequently obtained in patients with
syncope.
• In one review of 649 patients, 53 percent
had at least one neurologic test.
• However, such testing was rarely useful.
Syncope
Treatment
• Treatment should be aimed at the
underlying cause
• Avoid situations where if they faint they
may be injured; climbing, swimming,
driving, operating heavy machinery
Murmur
What is the most likely congenital heart
lesion detected for the first time in adult
patients ?
• Mitral Valve Prolapse
• Bicuspid Aortic Valve with Aortic Stenosis
• Atrial Septal Defect
• Congenital Coronary Artery Anomaly
Case
• A 23 year old comes in for a complete
physical exam.
• No symptoms
• No medications
• Negative review of systems
• Negative Family history for heart problems
• Negative past medical history
Case
• Physical exam is normal except for a III/VI
systolic ejection murmur at the upper left
sternal border with a widely split S2
Case I
• A 28 year old nonsmoking male without
significant past medical history presents
with chest pain and exertional dyspnea.
Review of symptoms in notable for a one
week history of antecedent flu like
symptoms . Physical examination show
jugular venous distention, scattered rales ,
S3, III/IV holosystolic murmur at the apex.
Case I
• His ECG show diffuse ST-T wave
changes.
• His troponin is normal
Case I
What is the most likely diagnosis?
• Pulmonary embolism
• Acute myocardial infarction
• Viral pericarditis
• Viral myocarditis
• Hypertrophic cardiomyopahty
Case II
• A 23 year old tall, female presents with
sudden, severe , sharp chest pain that
radiates to the back . It is worse if she lays
down . Her heart rate is 110 bpm. Her BP
is 132/76 in the left arm and not palpable
in the right arm.
• What is her most likely diagnosis?
Case III
• A 29 year old man comes to clinic for a
recent episode of syncope . He and his
friends were running to catch a campus
shuttle . He had sudden loss of
consciousness and awoke to find his
friends looking over him . He does not
recall what happened . He has never
fainted before . He has exertional
dyspnea.
Case III
• On exam he has a blood pressure of 100/
76 and a heart rate of 82 . His chest exam
is normal . He has a late peaking systolic
ejection murmur at the right upper sternal
border . His pulses are equal in all 4
extremities and are 1+ out of 4+.
• What is his most like diagnosis ?
Case IV
• A 35 year old women comes in for an
evaluation of a murmur and dyspnea. She
has had a murmur since childhood. She
has had three pregnancies without
problems . Her brother died suddenly at 38
years of age . She has been dyspneic the
last few months . She has no other
complaints.
Case IV
• Her blood pressure is 120/70. She has a
normal cardiac exam except for a midpeaking systolic murmur along her left
sternal border that increase during a
valsavla maneuver .
• What is the cause of her murmur?
Case V
• A 19 year old male athlete comes in for an
evaluation of fainting while swimming. He
has not other history or complaints .His
exam is normal.
Case V
• What is his likely diagnosis ?
Case VI
• 20year old asymptomatic female noted to
have frequent extra beats on physical
exam; patient asks if she should worry
• No prior history of heart disease;
physically fit; snorted cocaine when she
was a teenager
• Nonsmoker; no alcohol
• Physical exam normal except frequent
extra systoles
Case VI
What tests does she need ?
• Holter monitor; quantity, repetitive form
• Echocardiogram ; exclude structural heart
disease
• Exercise test; exclude exercise induced
ventricular tachycardia
• ECG; exclude log QT, etc.
Case VI
• No evidence that PVC suppression
prolongs life in structurally normal heart
• CAST study
• No treatment if asymptomatic, normal
exercise tolerance test, normal echo (if he
has unpleasant palpitations consider beta
blockers)
Case VII
• A 21 year old comes in for a racing heart .
It started while at a party last night . He is
healthy and is on no medications . His
heart rate is 110 and irregular . His exam
is unremarkable except for his irregular
heart rate .
Case VII
• Pneumonia
• Acute COPD
• Acute respiratory
failure
• Pulmonary embolism
• Elderly
• Acute MI
• CHF
• Valvular disease, esp.
mitral stenosis
• Hypertensive heart
• Idiopathic
• Alcohol
• Hyperthyroidism
Reference