Heartsink Patients

1. Heartsink Patients Tilting towards a diagnosis

3. What do you mean by Dizzy? I feel off balance Everything is spinning I�m lightheaded � I might faint I�m just dizzy, Doc!

5. Dizziness Vertigo Dysequilibrium Lightheadedness - presyncope Other

6. I feel off balance Sensiosomatic Peripheral neuropathy Proprioception Visual Multiple sensory deficits of Drachman & Hart Drugs Psychological Anxiety / depression Hyperventilation

7. Everything is spinning

8. Everything is spinning Peripheral vestibular problems Benign paroxysmal positional vertigo BPPV Meniere�s Disease Central vestibular and CNS problems Brainstem lesion Stroke MS Acoustic neuroma Cerebellar Epileptic aura

9. Benign paroxysmal positional vertigo Symptoms Episodic � especially marked early in the day Vertigo on looking up, looking round, lying down & rolling over Diagnostic test � Dix-Hallpike test Vertigo after brief latent period Rotational nystagmus Symptoms resolve in 20 � 30s Less severe on repeat manoeuvre

10. Benign paroxysmal positional vertigo Traditional therapy: Brandt-Daroff exercises Cawthorne-Cooksey exercises Exciting therapy! Epley maneouvre

21. Epley Manoeuvre Movie

22. Benign paroxysmal positional vertigo Traditional therapy: Brandt-Daroff exercises Cawthorne-Cooksey exercises

25. I feel lightheaded - I might faint Cardiovascular Arrhythmia � tachy/brady syndrome Ischaemia Aortic stenosis HOCM Postural hypotension

29. Postural hypotension Definition Systolic BP drop of 20 mmHg Diastolic BP drop of 10 mmHg with symptoms Prevalance 10% of elderly in the community 20 � 30% of elderly in institutions Diagnosis At least 5 minutes supine � establish basal reading Standing BP + HR at T = 0, 30s & 60 s

30. Postural hypotension Hypovolaemia Dehydration Blood loss Hyponatraemia Drugs Illness Vomiting / diarrhoea Addison�s Disease

31. Postural hypotension Drugs Anti-hypertensives Anti- PD Anti- depressants Anti-failure Autonomic neuropathy Diabetes Alcohol Neoplasm Amyloid Multiple system atrophy

32. Postural hypotension Investigations FBC + U&E Blood glucose Plasma viscosity PSA LFTs Synacthen test Autonomic nervous system function tests

35. Postural hypotension Exclude treatable causes � then: Education Raise bed head Compression stockings Increase salt intake Fludrocortisone � 50 mcg nocte initially Flurbiprofen Desmopressin Midodrine � oral alpha agonist

37. Presyncope/ syncope Vasovagal Simple faint Cough / micturation syncope Neurocardiogenic syncope Carotid sinus syndrome Hypoglycaemia Hyperventilation

38. Benign Vasovagal Syncope Commonest cause of syncope Most frequently in 30 - 50 age group Typical triggers - pain, fear, blood etc Prodromal symptoms Higher centres , including limbic system, involved

39. Neurocardiogenic Syncope Any age. Slightly more common in males No triggers Onset may be abrupt Often prodromal pallor, sweating or nausea Injury may occur Co-existing CVS disease rare Syncope reproduced on a Tilt Table

41. Tilt Table Test Head-up tilt - 70 degrees Two protocols: Westminster protocol � 40 minutes unprovoked Italian protocol � first 20 minutes unprovoked then 400 mcg GTN administered

42. Tilt Table Test Typical cardiovascular response: Increased vagal tone with heart rate slowing & hypotension Vagal tone may be intense leading to cardiac standstill Reproduction of patient�s syncopal symptoms Symptoms rapidly relieved by removing the tilt

48. Presyncopal bradycardia

56. Aldini (1762 - 1834) described the alleviation of cardiac syncope through "galvanic energy" utilising animal and cadaver studies.

57. Neurocardiogenic Syncope Management: Explanation Salt replacement Counter manoeuvres

62. Neurocardiogenic Syncope Management continued: Drugs: Beta blocker Fludrocortisone Midodrine SSRI Disopyramide

63. Carotid Sinus Syndrome Syncope precipitated by Turning round 52% Looking up 48% Presentation Prodromal symptoms - LOC 30% LOC with no prodromal symptoms 30% Drop Attacks - LOC but retrograde amnesia 20%

64. Carotid Sinus Syndrome Diagnosis Carotid Sinus Massage - 5 seconds to right carotid, then left. > 3 seconds asytole - cardio-inhibitory component or systolic BP drop > 50 mmHg - vasodepressor component Carotid Sinus Hypersensitivity

65. Carotid Sinus Syndrome Carotid Sinus Syndrome Carotid Sinus Hypersensitivity + symptoms

68. Carotid Sinus Syndrome Carotid sinus sensitivity is enhanced by: Digoxin Beta blockers Diltiazem Alpha Methydopa

69. Carotid Sinus Syndrome Management Stop drugs known to enhance carotid sinus sensitivity Dual-chamber pacing abolishes cardio-inhibitory component No effective treatment for vasodepressor component, but worth trying Fludrocortisone

71. Treatable causes for heartsink patients Benign paroxysmal positional vertigo Hyperventilation syndrome Neurocardiogenic syncope Carotid sinus syndrome

72. Syncope Clinic Unexplained falls Unexplained syncope Intermittent dizziness

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