A 70-year-old man is brought to the emergency department by his wife after he passed out earlier this morning. The patient was sitting in a chair watching TV when he lost consciousness for approximately 3 minutes before spontaneously recovering. He did not fall off the chair, and his wife did not observe any convulsive limb movements. There was no soiling of his clothes by urine or stool. She says, "Doc, it has never happened to him before. He was completely unresponsive and looked pale. I got really scared." In the emergency department the patient has no headache, nausea, chest discomfort, or shortness of breath. He has no recollection of what happened and did not feel anything out of the ordinary beforehand. Medical history includes hypertension, hyperlipidemia, type 2 diabetes mellitus, and coronary artery disease. The patient had an anterolateral myocardial infarction 2 years ago and underwent coronary stent placement. Since then, he has had no episodes of angina. His lifestyle is sedentary and he spends little time outdoors. He becomes short of breath when climbing a flight of stairs. On initial evaluation the patient appears comfortable and asks if he can go home. Temperature is 36.7 C (98 F), blood pressure is 130/86 mm Hg sitting and 125/85 mm Hg standing, pulse is 78/min, and respirations are 16/min. Pulse oximetry shows 98% on room air. Neurologic examination is nonfocal. ECG shows normal sinus rhythm with anterolateral Q waves, unchanged from prior ECG. Blood cell counts, serum chemistry studies, and chest x-ray are within normal limits. Which of the following is the most appropriate next step in management of this patient?

Question

A 70-year-old man is brought to the emergency department by his wife after he passed out earlier this morning.  The patient was sitting in a chair watching TV when he lost consciousness for approximately 3 minutes before spontaneously recovering.  He did not fall off the chair, and his wife did not observe any convulsive limb movements.  There was no soiling of his clothes by urine or stool.  She says, "Doc, it has never happened to him before.  He was completely unresponsive and looked pale.  I got really scared."  In the emergency department the patient has no headache, nausea, chest discomfort, or shortness of breath.  He has no recollection of what happened and did not feel anything out of the ordinary beforehand.  Medical history includes hypertension, hyperlipidemia, type 2 diabetes mellitus, and coronary artery disease.  The patient had an anterolateral myocardial infarction 2 years ago and underwent coronary stent placement.  Since then, he has had no episodes of angina.  His lifestyle is sedentary and he spends little time outdoors.  He becomes short of breath when climbing a flight of stairs.  On initial evaluation the patient appears comfortable and asks if he can go home.  Temperature is 36.7 C (98 F), blood pressure is 130/86 mm Hg sitting and 125/85 mm Hg standing, pulse is 78/min, and respirations are 16/min.  Pulse oximetry shows 98% on room air.  Neurologic examination is nonfocal.  ECG shows normal sinus rhythm with anterolateral Q waves, unchanged from prior ECG.  Blood cell counts, serum chemistry studies, and chest x-ray are within normal limits.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be65_b64a_8f63_4fe2eb19bb01_MD0005_00 This patient most likely experienced cardiac syncope due to ventricular tachycardia (VT). Syncope due to VT usually has no warning symptoms (other than palpitations in some patients). The arrhythmia spontaneously terminates within a few minutes, resulting in cardiac output restoration and rapid patient recovery with no residual symptoms. Recognition of cardiac syncope is crucial due to the high risk of sudden cardiac death. Absence of autonomic prodromal symptoms (eg, nausea, diaphoresis, feeling of warmth), which are usually present prior to a benign syncopal event, suggests cardiac syncope. The presence of underlying structural heart disease (eg, Q waves suggesting ischemic scarring from previous myocardial infarction, cardiomyopathy with low ejection fraction) specifically suggests cardiac syncope due to VT. This patient should be admitted to undergo telemetry monitoring (to attempt to detect arrhythmia) and echocardiography (to evaluate left ventricular function and identify wall motion abnormality). Depending on the findings, treatment with some combination of pharmacologic therapy (eg, amiodarone), catheter ablation, or placement of an implantable cardiac defibrillator may be indicated. (Choice B) This patient is at risk of experiencing recurrent VT that could result in sudden cardiac death; therefore, discharge home with a Holter monitor is not appropriate and inpatient monitoring and workup are indicated. (Choice C) CT scan of the head without contrast is appropriate for patients with suspected stroke or seizure or following a fall, but it is not indicated in the workup of syncope. This patient did not fall off the chair and has no evidence of trauma, has no focal neurologic deficits (making stroke less likely), and experienced no abnormal movements or incontinence (making seizure less likely). (Choice D) This patient may require coronary angiography if echocardiogram shows a new wall motion defect or markedly reduced left ventricular ejection fraction; however, coronary angiography is not indicated prior to other workup. (Choice E) Reassurance and discharge home with syncope education are appropriate following vasovagal syncope, commonly triggered by prolonged standing or emotional stress and usually accompanied by autonomic prodrome. This patient's absence of prodrome and history of ischemic heart disease make cardiac syncope more likely. Temporary pallor may occur with any cause of syncope due to transient hypoperfusion. Educational objective: Cardiac syncope due to ventricular tachycardia is suggested by the abrupt onset of syncope without prodrome and the presence of underlying structural heart disease. These patients are at risk of sudden cardiac death and require definitive evaluation and management. References: Guidelines for the diagnosis and management of syncope. (http://www.ncbi.nlm.nih.gov/pubmed/19713422) Syncope: a review of emergency department management and disposition. (http://www.ncbi.nlm.nih.gov/pubmed/27752576)

A 70-Year-Old Man Is Brought to the Emergency Department by His