Cardiovascular Syncope Management

Blood Pressure Monitoring

• Continuous non-invasive beat-to-beat blood pressure monitoring can be facilitated with finometry, which involves a device placed on the arm.
• This allows for more frequent blood pressure monitoring.

Reflex Syncope

• Reflex syncope should be considered in the absence of heart disease and with head rotation or carotid sinus pressure.
• Carotid sinus syndrome is a type of reflex syncope associated with neck movements like head turning, shaving, tight collars, etc.
• All patients over 40 years of age who experience syncope of an unknown origin should be evaluated for carotid sinus syndrome (CSS) with carotid sinus massage (CSM).
• Carotid sinus pressure or head rotation, which may be brought on by tumors, shaving, or tight collars, or turning the head, are CSS triggers.
• CSS can be identified by a carotid sinus massage lasting 10 seconds that results in syncope accompanied by asystole lasting longer than 3 seconds and/or a drop in systolic blood pressure of more than 50 mm Hg.

Diagnosis and Treatment

• Abdominal binders and compression stockings can help aid venous return if venous pooling is an issue.
• Head-up tilt sleeping helps avoid nocturnal hypotension.
• An ambulatory blood pressure monitor (ABPM) is a useful test in patients with dual diagnoses of OH and hypertension.
• An ABPM can identify nocturnal hypertension which can especially occur with pharmacologic treatments for OH.

Vertigo

• Vertigo is a false sense of motion and perhaps a sensation of spinning.
• Vertigo is categorized as peripheral or central.
• Vertigo is not a phobia of heights and is not necessarily dizziness.
• The HINTS examination is a test that carefully assesses eye movements to determine if vertigo is of a central cause, such as a stroke, or a peripheral cause, such as vestibular neuronitis.

HINTS Test

• A worrying HINTS test that suggests a central cause for vertigo is either bidirectional nystagmus, a positive skew test, or a negative head impulse test.
• In a person with nystagmus, a HINTS test would have nystagmus in one direction, no skew, and a positive head impulse test.

Orthostatic Hypotension (OH)

• Even though a case initially suggests orthostatic hypotension, initial investigations must be carried out to rule out high-risk cardiac causes.
• If a new cardiac murmur was detected in the aortic area during physical examination, a structural cardiac cause like aortic stenosis would have to be considered and an echocardiogram would be appropriate.