Common Cardiac Complaints in College Students Victoria E Judd MD, FACC University of Utah

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 PainCase

• 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

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 PainHistory

• 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

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* Risk factor Percent

• Physical stress with MI 39• Obesity alone 30• Sympathomimetic drug use 7 • Estrogen or oral contraceptive pill use 6• Valvular heart disease 3• Collagen vascular disease 2 • Cardiomyopathy 2• History chest irradiation 1• Myocarditis 1• Chronic dysrhythmia 1 • Sickle cell anemia <1• Coronary artery spasm 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 PainHistory

• Exertional or non-exertional

• Cardiac Risk Factors

• Previous Cardiac History

• Previous GI History

• Previous Pulmonary History

• Recent Prolonged Immobility

• Drugs; cocaine, methamphetamines

Chest PainPhysical 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 PainCase 1

• 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 PainCase

• 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 PainLabs

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 PainDifferential Diagnosis

• Angina• Myocardial Infarction• Aortic Stenosis• Aortic Dissection• Pericarditis• Pulmonary Hypertension• Pulmonary Embolism• Pneumonia

Chest PainDifferential Diagnosis

• 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?

DyspneaDefinition , etc.

• An abnormally uncomfortable awareness of breathing

• As with all disease individual perceptions, general physical condition , school history, work history, recreational habits are important

DyspneaCase

• 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.

DyspneaCase

• 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

DyspneaCardiac 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)

DyspneaPulmonary Causes of

• Pneumonia• Asthma• Pulmonary embolus• Pneumothorax• Pulmonary fibrosis• Pulmonary hypertension• Pleural Effusion• Chronic obstructive pulmonary disease

DyspneaOther Causes of

• 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

• 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.

DyspneaHistory

• 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)

DyspneaHistory

• 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.

DyspneaCase

• No Jugular Venous Distension

• Chest is clear

• Normal cardiac exam

• No peripheral edema

• No calf tenderness

DyspneaPhysical Exam

• 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

DyspneaDiagnostic Evaluation

• Chest X-Ray

• Complete Blood Count; anemia

• Pulmonary Function Tests

• ECG

• Echocardiogram

• Serum brain natriuretic peptide (BNP)

http://www-medlib.med.utah.edu/kw/ecg/index.html

DyspneaDifferential Diagnosis

Cardiac

• Congestive Heart Failure

• Ischemia

• Valvular Heart Disease

• Pericardial ( Tamponade, Constriction)

• Restrictive Heart Disease ( Infiltrative or Hypertrophic Heart Disease)

DyspneaDifferential Diagnosis

Pulmonary• COPD• Asthma• Pneumonia• Pleural Effusion• Pulmonary Embolism• Pneumothorax• Pulmonary Fibrosis• Pulmonary Hypertension• Airway Obstruction

DyspneaDifferential Diagnosis

Other

• Anemia

• Hyperthyroidism

• Diaphragmatic Paralysis

Case

• ? Cause

• Dyspena without other findings = Pulmonary embolus until proven otherwise

PalpitationsDefinition, 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 .

PalpitationsCase 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

PalpitationsCase

• Physical exam is normalWhat 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.

PalpitationsHistory

• 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

PalpitationsPhysical Exam Clues

• 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.

SyncopeDefinition, 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

Kapoor: Medicine, 1990Kapoor: Medicine, 1990

102030405060

0 1 2 3 4 5 0 1 2 3 4 5

Year of follow-up

%

CardiogenicUndeterminedNoncardiac

Mortality Sudden Death

SyncopeNatural 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 syncopeGlossopharyngeal 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.

SyncopeHistory

• 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

SyncopeHistory

• 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?

SyncopeHistory

• 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 life-threatening 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 tonic-clonic 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

SyncopeCase

• 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

SyncopePhysical 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

SyncopeCase; Tests

What test should be done?• Hematocrit• Electrolytes, glucose• Pregnancy test• ECG• Echocardiogram• 24 hour holter monitoring• Event monitor• Electrophysiological testing

SyncopeCase; 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.

SyncopeTreatment

• 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 mid-peaking 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