A 22-year-old woman comes to the office due to recurrent syncopal episodes. The first episode occurred about a year ago when her roommate died by suicide. Since then, she has had several similar episodes provoked by strong emotion. The episodes are preceded by lightheadedness, weakness, and blurred vision; last about 3 minutes; and end with rapid recovery of consciousness. The patient has had no significant injuries related to syncope except once when she had superficial bruises. Medical history is insignificant. She takes no medications and does not use alcohol or illicit drugs. Blood pressure is 110/70 mm Hg while supine and 108/70 mm Hg while standing. Physical examination findings are within normal limits. A recent ECG was normal. Which of the following is the best next step in management of this patient?

Question

A 22-year-old woman comes to the office due to recurrent syncopal episodes.  The first episode occurred about a year ago when her roommate died by suicide.  Since then, she has had several similar episodes provoked by strong emotion.  The episodes are preceded by lightheadedness, weakness, and blurred vision; last about 3 minutes; and end with rapid recovery of consciousness.  The patient has had no significant injuries related to syncope except once when she had superficial bruises.  Medical history is insignificant.  She takes no medications and does not use alcohol or illicit drugs.  Blood pressure is 110/70 mm Hg while supine and 108/70 mm Hg while standing.  Physical examination findings are within normal limits.  A recent ECG was normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d58a_c18e_bc81_fd005b97b486_MD0003_00 Vasovagal syncope, a type of reflex syncope, can be triggered by emotional or painful stimuli and is frequently associated with prodromal symptoms (eg, dizziness, nausea, pallor, diaphoresis, abdominal pain, generalized sense of warmth) prior to the syncopal episode. The prognosis is excellent. For patients with recurrent syncope, management consists of advice to avoid triggers and to assume a supine position with leg raising at the onset of symptoms. Physical counterpressure maneuvers (eg, leg crossing with tensing of muscles, handgrip and tensing of arm muscles with clenched fists) during the prodromal phase can improve venous return and cardiac output, sometimes aborting syncopal episodes. Some patients in high-risk settings associated with a potential risk of physical injury (eg, airline pilots, commercial drivers) require temporary activity restriction until these maneuvers are proven effective. (Choice A) Holter monitoring is indicated in patients with clinical or electrocardiographic features suggesting the presence of an underlying arrhythmia. This is usually suspected in patients with underlying heart disease who have syncopal episodes (often without specific triggers or prodromal symptoms). (Choice B) Carotid sinus hypersensitivity refers to recurrent episodes of presyncope or syncope triggered by pressure on the carotid sinuses (eg, due to tight neck collar and neck movements). It can often be reproduced by carotid sinus massage, which is considered diagnostic if patients develop asystole, a fall in systolic blood pressure, or reproduction of symptoms (eg, syncope) with the maneuver. (Choice D) Beta blockers have shown no significant benefits in randomized trials in patients with vasovagal syncope (although they are occasionally used in such patients). (Choice E) Transthoracic echocardiography should be performed in patients with syncope when structural or valvular heart disease is suspected due to history or physical examination (eg, syncope during exertion, abnormal murmurs). Educational objective: General treatment measures in patients with vasovagal syncope include reassurance and education about the benign nature of the condition. Patients should be advised to avoid triggers and to use physical counterpressure maneuvers during the prodromal phase to abort or delay an episode of syncope. References: Effectiveness of physical counterpressure maneuvers in preventing vasovagal syncope: the Physical Counterpressure Manoeuvres Trial (PC-Trial). (http://www.ncbi.nlm.nih.gov/pubmed/17045903) Syncope: epidemiology, etiology, and prognosis. (http://www.ncbi.nlm.nih.gov/pubmed/25538626) Physical manoeuvers as a preventive intervention to manage vasovagal syncope: A systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/30818337)

A 22-Year-Old Woman Comes to the Office Due to Recurrent