A 78-year-old man is evaluated for syncope. He was hospitalized a week ago after passing out in his garden and sustaining a minor head injury. He had no prodromal symptoms, chest pain, or palpitations. After the syncopal episode, he was not confused and had only a mild headache due to trauma. Four months ago, the patient had a similar episode at home but sustained no injuries. He has hypertension, for which he takes lisinopril and amlodipine. He does not use tobacco, alcohol, or illicit drugs. He walks 4 miles a day.
Blood pressure is 140/90 mm Hg supine and 138/88 mm Hg standing, and pulse is 75/min and regular. Fourth heart sound is heard on cardiac auscultation. There are no carotid bruits. Carotid sinus massage does not provoke long pauses.
Electrocardiogram shows normal sinus rhythm with tall R waves. An echocardiogram done in the hospital showed left atrial enlargement, left ventricular hypertrophy, and ejection fraction of 60%.
Which of the following is the best next step in management of this patient?

Question

A 78-year-old man is evaluated for syncope.  He was hospitalized a week ago after passing out in his garden and sustaining a minor head injury.  He had no prodromal symptoms, chest pain, or palpitations.  After the syncopal episode, he was not confused and had only a mild headache due to trauma.  Four months ago, the patient had a similar episode at home but sustained no injuries.  He has hypertension, for which he takes lisinopril and amlodipine.  He does not use tobacco, alcohol, or illicit drugs.  He walks 4 miles a day.
Blood pressure is 140/90 mm Hg supine and 138/88 mm Hg standing, and pulse is 75/min and regular.  Fourth heart sound is heard on cardiac auscultation.  There are no carotid bruits.  Carotid sinus massage does not provoke long pauses.
Electrocardiogram shows normal sinus rhythm with tall R waves.  An echocardiogram done in the hospital showed left atrial enlargement, left ventricular hypertrophy, and ejection fraction of 60%.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_976e_2c2e_853d_3d1087e94d6d_MD0002_00 Although syncope is usually benign and self-limiting, it can be the initial presenting symptom of a life-threatening disease process. This patient has recurrent syncopal episodes that occur infrequently (months apart) with no prodromal symptoms. He does not have carotid sinus hypersensitivity. As a result, the next step in management is to proceed with continuous ambulatory electrocardiographic monitoring with an implantable loop recorder (ILR) to assess for arrhythmias and conduction abnormalities. syncope An ILR is a subcutaneous monitoring device for the detection of cardiac arrhythmias. It has a significantly higher diagnostic yield than shorter-term monitoring when symptoms occur infrequently (<1 event/month). An ILR can provide continuous monitoring for months to years, increasing the likelihood of determining the cause of syncope. < (Choice A) This patient has occasional episodes of syncope (2 episodes in 4 months) and has no other symptoms between episodes. A 24-hour monitor would have a very low diagnostic yield in this setting. (Choice B) Dizziness or syncope can occur from orthostatic hypotension or from an excessive drop in blood pressure due to antihypertensive therapy. This effect is more often seen 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 medications is not indicated. orthostatic hypotension (Choice C) Features suggestive of seizures include the presence of triggers (eg, lack of sleep, emotional stress, loud music, flashing lights), a prolonged postictal phase with confusion and disorientation, prodromal aura, head deviation or unusual body posturing, and tongue laceration. This patient has no such history, and an electroencephalogram would not be helpful. (Choice E) A permanent cardiac pacemaker is not indicated at this time without a clear diagnosis of the syncopal episodes. Educational objective: An implantable loop recorder is a subcutaneous monitoring device for the detection of cardiac arrhythmias. It has a significantly higher diagnostic yield than 24-hour Holter monitoring in patients with infrequent (<1 event/month) symptoms of palpitations or syncope of undetermined etiology. < __________ References: Early application of an implantable loop recorder allows effective specific therapy in patients with recurrent suspected neutrally mediated syncope. (http://www.ncbi.nlm.nih.gov/pubmed/16569653) Use of implantable loop recorders in the diagnosis and management of syncope. (http://www.ncbi.nlm.nih.gov/pubmed/15246645)

A 78-Year-Old Man Is Evaluated for Syncope