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Diagnostic Pivot --> Syncope is different from fall given LOC
Syncope Dx:
-Vasovagal --> elderly have less vagal tone/symptoms
-Arrhythmia
-Seizure (post-ictal and lateral tongue laceration most specific sign/symptom)
-Valvular Disease
Most important test for syncope --> orthostatics
-48 hours of tele is reasonable to catch arrhythmia (yield doubles from 24-48 hrs but diminishing returns after this)
Posted 06/03/16 01:58:28 PM by Adam Faye
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4 Phases of valsalva (blow against higher pressure than CVP)
- Systolic pressure rises against increased intro-thoracic pressure
- Venous return declines
- Systolic pressure declines
- Venous return increases and BP increases (reflex brady, measure of barorecepter function). IF in chronic CHF (elevated CVP), no stage 2-4 (square root sign)
Posted 06/03/16 02:05:28 PM by Adam Faye
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HCM:
- Reduction in preload increases LVOT/murmur --> valsalva or squat to stand
- Increasing afterload (handgrip) decreases gradient and reduces murmur
SAM - Systolic anterior motion; MV presses against septum causing obstruction of LVOT during systole
(Venturi effect, dragging, or enlarged pappilary muscle/chordae that mechanically block LVOT)
Therapy (Gradient above 50 considered high)
-Disopyramide - initiate in hospital to monitor QTc; usually used to treat atrial arrhythmias; has negative inotropic effect to lower gradient
-Beta Blocker increases filling time in HOCM
Posted 06/03/16 02:09:16 PM by Adam Faye
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Risk Stratification for HCM:
5 high risk features (if you have 2 or more, your risk of sudden death outweighs risk of AICD. 1/5 is 1-2% risk of sudden death)
- Family history of sudden death
- Septum > 3cm
- Syncope
- non-sustained VT on a holter (more predictive in younger patients)
- Drop in BP with exercise
Posted 06/03/16 02:17:17 PM by Adam Faye
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For further reading...
Posted 06/03/16 02:23:20 PM by Adam Faye