A 62-year-old business executive comes to the office due to episodes of lightheadedness over the last 6 months. These happen primarily in the morning when he is getting dressed. During these episodes, the patient feels that the room "is getting dark" and that he is going to pass out. One time, he briefly lost consciousness. He has no nausea, chest pain, palpitations, headaches, vision problems, shortness of breath, tongue bites, or urinary incontinence. His medications include valsartan for high blood pressure. The patient is a former smoker with a 25-pack-year history.
His blood pressure is 134/85 mm Hg while supine and 140/82 mm Hg after standing for 2 minutes, and pulse is 72/min. There are no heart murmurs or carotid bruits. Lungs are clear on auscultation. Peripheral pulses are full and symmetric in all 4 extremities. ECG shows normal sinus rhythm.
Which of the following is the best next step in the evaluation of this patient?

Question

A 62-year-old business executive comes to the office due to episodes of lightheadedness over the last 6 months.  These happen primarily in the morning when he is getting dressed.  During these episodes, the patient feels that the room "is getting dark" and that he is going to pass out.  One time, he briefly lost consciousness.  He has no nausea, chest pain, palpitations, headaches, vision problems, shortness of breath, tongue bites, or urinary incontinence.  His medications include valsartan for high blood pressure.  The patient is a former smoker with a 25-pack-year history.
His blood pressure is 134/85 mm Hg while supine and 140/82 mm Hg after standing for 2 minutes, and pulse is 72/min.  There are no heart murmurs or carotid bruits.  Lungs are clear on auscultation.  Peripheral pulses are full and symmetric in all 4 extremities.  ECG shows normal sinus rhythm.
Which of the following is the best next step in the evaluation of this patient?

Quizplus · Accepted Answer

This patient has recurrent episodes of presyncope and an episode of syncope without an apparent discernible cause. A detailed initial evaluation can provide several clues to the underlying etiology of syncope in a majority of patients. His history is suggestive of carotid sinus hypersensitivity, triggered by pressure on the carotid sinus by a tight collar and neck movements while getting dressed in the morning. Another common trigger is shaving the neck area. underlying etiology of syncope Carotid sinus massage is considered diagnostic if the patient develops syncope along with asystole for >3 seconds and/or there is a fall in systolic blood pressure of >50 mm Hg. No additional workup is needed for diagnosing carotid sinus hypersensitivity. Carotid sinus massage should be avoided in patients with ipsilateral carotid artery stenosis or carotid bruits and/or a history of transient ischemic attack or stroke within the past 3 months. Treatment requires permanent pacing. (Choice B) Dizziness or syncope can occur from hypotension due to medication use. These are more common in patients with volume depletion or hypovolemia due to concomitant use of diuretics. This patient has adequate blood pressure with no orthostatic change with standing, and discontinuation of valsartan is not indicated. (Choice C) The Dix-Hallpike maneuver is used to diagnose benign paroxysmal positional vertigo due to posterior canal dysfunction in those with a history of positional dizziness or vertigo. Patients may have associated nausea and vomiting. This patient's history of episodic lightheadedness in the morning while getting dressed is more suggestive of carotid sinus hypersensitivity. (Choice D) This patient's clinical presentation is not consistent with a seizure disorder. Neurologic testing, including electroencephalogram, brain CT or MRI, and carotid Doppler ultrasound, is not routinely indicated in patients with recurrent presyncope or syncope unless the initial evaluation suggests a non-syncopal cause of transient loss of consciousness. (Choice E) Exercise stress testing is recommended in patients with a history of syncope during or shortly after exertion and/or in some patients with prior history of coronary artery disease. It has a low overall yield in patients with syncope and is not routinely indicated. Educational objective: Carotid sinus massage testing is recommended in patients age >40 with syncope of uncertain etiology to diagnose carotid sinus hypersensitivity. Carotid sinus massage is considered diagnostic if the patient develops syncope along with asystole for >3 seconds and/or there is a fall in systolic blood pressure of >50 mm Hg. It should be avoided in patients with ipsilateral carotid artery stenosis or carotid bruits and/or history of transient ischemic attack or stroke within the past 3 months. Treatment requires permanent pacing. __________ References: Guidelines for the diagnosis and management of syncope (version 2009). (http://www.ncbi.nlm.nih.gov/pubmed/19713422) Unexplained syncope--is screening for carotid sinus hypersensitivity indicated in all patients aged >40 years? (http://www.ncbi.nlm.nih.gov/pubmed/16735395) The role of pacemaker in hypersensitive carotid sinus syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/21169606)

A 62-Year-Old Business Executive Comes to the Office Due to Episodes