Case study 2: Opal—Dizzy doing dishes
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A 72-year-old woman passed out when she turned her head to answer a question from her son while reaching to get dishes from a high cupboard. She felt dizzy for a few seconds before she lost consciousness. No chest pain.
- No known CHD. No FH. No cigarettes or diabetes. + Htn.
- Meds: HCTZ (htn); alendronate (osteoporosis).
- PE: Thin woman. BP 150/94, P 84 regular supine, and BP 146/96, P 90 standing.
- Carotids: No bruits. 1/6 systolic murmur at RSB without radiation. Pedal pulses present.
- ECG: NSR with borderline LVH by voltage.
- Non-fasting cholesterol: 200 with HDL 52.
question
Which of the following is most likely to confirm the diagnosis?
Neurocardiogenic syncope
- Inappropriate neuro-cardiac feedback.
- Vasovagal most common.
- Associated with nausea and diaphoresis.
- Stress, emotion, or pain, exercise, defecation, or urination.
- Precipitated by turning her head, “dizzy” for a few seconds—suggests decreased perfusion.
- Arterial US is the test of choice.
- Nylen-Baranay maneuver helps rule out vertigo.
- Carotid sinus massage for 5–20 seconds on each side of the neck (sequentially) while checking the pulse (or a rhythm strip) and blood pressure for asystole > 3 seconds or a fall in SBP of 50 points is diagnostic.
- Safe in patients without carotid bruits.
- If known or suspected CHD: Full cardiac evaluation beginning with echocardiogram.
- Often multifactorial.
- Eliminate causative medications.
- If orthostatic:
- Increase salt intake.
- Consider fludrocortisone.
- Gait training in the elderly.
- If has Parkinson Disease, consider droxidopa (norepinephrine precursor) with carbidopa.
- Reconsider cardiac causes.
- Reconsider psychiatric issues.
Blame it on the drugs
The list is long!
Polypharmacy—especially in the elderly:
Antihypertensives, especially vasodilators.
Tricyclic antidepressants.
Anticholinergic medications.
Benzodiazepines.
Opiates.
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