Uther lecture: Evaluating Syncope and Palpitations SYNCOPE just means a blackout. Got to ask yourself: IS IT OF CARDIAC ORIGIN?? Could it be epileptic, hypoglycaemic, vasovagal? Were there any witnesses whose account may help you? Typical Historical Picture: Retrograde amnesia, previous lesser “pre-syncope” events No warning of attack Short term of attack (few minutes) Change in colour (turning blue-grey) Typical Physical Exam Picture: Heart disease signs Postural hypotension Absent reflexes of autonomic neuropathy Murmurs and obstructive signs PALPITATIONS mean an unpleasant awareness of heartbeat- and not just the thumping rhythm after exercise. Must find out: SITE OF SENSATION = chest or neck? Precipitating and relieving factors? Associated sweating, angina, presyncope or syncope? Young people can still get “functional” angina in absence of coronary artery disease. Is there a family history of SUDDEN CARDIAC DEATH? So lets assume its cardiac. 2 major causes of cardiogenic syncope are ACUTE OBSTRUCTION and ARRHYTHMIA ARRHYTHMIA: most common; diagnose by exam + ECG BRADY or TACHY? Management: key goals are to CONTROL VENTRICULAR RATE (using beta blockers to slow it down or isoprenaline to speed it up) MAINTAIN NORMAL ATRIO-VENTRICULAR SYNCHRONY i.e cardiovert RESTORE NORMAL VENTRICULAR ACTIVATION i.e cardiovert and or pace the heart (pacemaker needed), and/or ablate the abnormal activation pathway RESTORE REGULARITY This may mean pacemaker, external pacing, or regular anyarrhythmic meds. Basically, keep em out of asystole until you can put a pacemaker in. OBSTRUCTION: not as common, diagnose by exam and ECHO Valve obstruction eg. stenosis Valve malfunction eg. sudden papillary tendon rupture and regurg. Main vessel obstruction eg. atrial myxoma blocking valve, or massive PE ASK about oddities in family: Excessive avoidance of bizarre self- identified triggers leads to a STRANGE LIFESTYLE of a person who’s afraid of arrhythmias.

Syncope and Palpitations

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Uther lecture: Evaluating Syncope and Palpitations

SYNCOPE just means a blackout.Got to ask yourself:IS IT OF CARDIAC ORIGIN??Could it be epileptic, hypoglycaemic,vasovagal? Were there any witnesseswhose account may help you?

Typical Historical Picture:Retrograde amnesia,previous lesser “pre-syncope” eventsNo warning of attackShort term of attack (few minutes)Change in colour (turning blue-grey)Typical Physical Exam Picture:Heart disease signsPostural hypotensionAbsent reflexes of autonomic neuropathyMurmurs and obstructive signs

PALPITATIONS mean an unpleasantawareness of heartbeat- and not justthe thumping rhythm after exercise.Must find out:SITE OF SENSATION

= chest or neck?Precipitating and relieving factors?

Associated sweating, angina,presyncope or syncope?Young people can still get “functional” angina inabsence of coronary artery disease.

Is there a family history of

SUDDEN CARDIAC DEATH?

So lets assume its cardiac.2 major causes of cardiogenic syncope areACUTE OBSTRUCTION and ARRHYTHMIA

ARRHYTHMIA: most common; diagnose by exam + ECGBRADY or TACHY?Management:key goals are to CONTROL VENTRICULAR RATE

(using beta blockers to slow it down or isoprenaline to speed it up) MAINTAIN NORMAL ATRIO-VENTRICULAR SYNCHRONY

i.e cardiovert

RESTORE NORMAL VENTRICULAR ACTIVATIONi.e cardiovert and or pace the heart (pacemaker needed), and/or ablate theabnormal activation pathway

RESTORE REGULARITY This may mean pacemaker, external pacing, or regular anyarrhythmic meds.Basically, keep em out of asystole until you can put a pacemaker in.

OBSTRUCTION: not as common, diagnose by exam and ECHO

Valve obstruction eg. stenosis Valve malfunction eg. sudden papillary tendon rupture and regurg. Main vessel obstruction eg. atrial myxoma blocking valve, or massive PE

ASK about oddities in family:Excessive avoidance of bizarre self-identified triggers leads to a

STRANGE LIFESTYLE of a person who’safraid of arrhythmias.