• 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

• 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

• 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

• 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

• For further reading...

  HCM Review
  NEJM HCM case 
  
  

  Posted 06/03/16 02:23:20 PM by Adam Faye

Created by Christopher Kelly

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