A 22-year-old woman is brought to the office by her mother because "she has been passing out." The patient's first episode occurred about a year ago when she split up with her boyfriend. A more recent episode was also provoked by strong emotion. Both episodes were preceded by nausea, light-headedness, weakness, and blurred vision, lasted about a minute, and ended with rapid recovery of consciousness. The patient sustained no significant injuries in either episode. She is concerned because one of her childhood friends passed out and died while playing football. Medical history is otherwise insignificant. The patient takes no medications and does not use alcohol or illicit drugs. She has no family history of early coronary artery disease, cardiomyopathy, or sudden cardiac death. Blood pressure is 110/70 mm Hg while supine and 108/70 mm Hg while standing. Physical examination findings are within normal limits. ECG reveals no abnormalities. Complete blood count and serum chemistries are within normal limits. Which of the following is the best next step in management of this patient?

Question

A 22-year-old woman is brought to the office by her mother because "she has been passing out."  The patient's first episode occurred about a year ago when she split up with her boyfriend.  A more recent episode was also provoked by strong emotion.  Both episodes were preceded by nausea, light-headedness, weakness, and blurred vision, lasted about a minute, and ended with rapid recovery of consciousness.  The patient sustained no significant injuries in either episode.  She is concerned because one of her childhood friends passed out and died while playing football.  Medical history is otherwise insignificant.  The patient takes no medications and does not use alcohol or illicit drugs.  She has no family history of early coronary artery disease, cardiomyopathy, or sudden cardiac death.  Blood pressure is 110/70 mm Hg while supine and 108/70 mm Hg while standing.  Physical examination findings are within normal limits.  ECG reveals no abnormalities.  Complete blood count and serum chemistries are within normal limits.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be64_f2f9_8f63_a9a42eb84a9a_MD0005_00 This patient has experienced recurrent vasovagal syncope, a type of reflex syncope. It is typically triggered by emotional distress, prolonged standing, or painful stimuli, and patients usually experience an autonomic prodrome with nausea, pallor, diaphoresis, or generalized warmth. Spontaneous resolution of the episode occurs within seconds to a few minutes. Patients with vasovagal syncope have an excellent prognosis, and the initial approach is aimed at providing education and reassurance. Patients are advised to avoid triggers and to assume a supine position with raised legs at the onset of prodromal symptoms. In addition, patients may be taught physical counterpressure maneuvers (eg, leg crossing with tensing of muscles, tensing of arm muscles with clenched fists) to improve venous return and cardiac output, and abort an episode of vasovagal syncope during the prodromal phase. (Choice A) 24-hour Holter monitoring may be indicated to assess for cardiac syncope in patients who have clinical features (eg, syncope without autonomic prodrome) or ECG findings suggesting cardiac arrhythmia. Cardiac syncope is unlikely in this young patient who has classic features of vasovagal syncope (eg, provoked by emotion, autonomic prodrome) and normal physical examination and ECG findings. (Choice C) Beta blockers were once thought to interfere with the neurologic pathways responsible for vasovagal syncope; however, these drugs have shown no benefit in preventing vasovagal syncope in randomized trials and are not recommended. (Choice D) Transthoracic echocardiography should be performed in patients with syncope and clinical features (eg, exertional syncope, abnormal cardiac murmur) suggestive of structural heart disease (eg, aortic stenosis). It is not indicated in this patient with a history consistent with vasovagal syncope and a normal physical examination. (Choice E) Vasovagal syncope is usually a clinical diagnosis that requires no further testing if history and physical examination are supportive (as in this case). Upright tilt table testing is typically reserved for patients with an unclear cause of syncope (eg, to differentiate vasovagal syncope from orthostatic syncope). Educational objective: The initial management of vasovagal syncope is aimed at providing education and reassurance about its benign nature and prognosis and advising patients to avoid potential triggers of syncope. In patients with recurrent episodes, physical counterpressure maneuvers can abort or delay an episode of syncope and are recommended during the prodromal phase. References: Reflex syncope: Diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/29255499)

A 22-Year-Old Woman Is Brought to the Office by Her