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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
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Syncope Practical Tips
• The use of broad-based investigations in the workup of syncope is
ineffective and costly
• Know what constitutes low vs. high risk on
– History [Fam Hx Sudden cardiac death, symptoms sounded ischemic, syncope while
exercising or lying supine or without prodrome, trauma due to syncope, known CVD]
– Exam [abnormal vitals or cardiac exam]
– Labs [elevated cardiac biomarkers]
– ECG [any brady or tachy arrhythmia or conductive abnormality]
• Cardiac testing (i.e. echocardiogram or stress testing) should be
based on high clinical suspicion of ischemic, structural, or valvular
heart disease
• Stress testing should be performed for patients who present with
syncope that occurs before, during, or after exertion
CCS Syncope 2020
https://t.me/medicina_free
Syncope Practical Tips
• Brain imaging should be performed only for patients for whom
intracranial disease is highly suspected as a possible contributing
cause to syncope, or if there has been a suspicion of head trauma
• Carotid artery imaging in the absence of focal neurological
findings should not be performed
• A tilt-table test should be considered only when there is
diagnostic uncertainty; usually this includes atypical
presentations, older patients with few clues in the history,
distinguishing convulsive syncope from epilepsy, and
nonhemodynamic collapses.
CCS Syncope 2020
https://t.me/medicina_free
Cardiac Monitoring
CCS Syncope 2020
https://t.me/medicina_free
Select Management Strategies in Syncope
CCS Syncope 2020
Vasovagal Syncope
(VVS)
- Education / reassurance
- avoid triggers
- Increased H2O and Na+
- Counterpressure maneuvers
Drugs for recurrent and
refractory VVS:
1
st
line Fludrocortisone or
Midodrine
2
nd
line Beta blocker (age >42)
Combo therapy sometimes
needed for refractory cases
Orthostatic Hypotension
- Education
- Avoid triggers
- increased H2O and Na+
- Medication review
- Compression garments
- Head-up tilt sleeping
Failing non-pharm management:
- Fludrocortisone
- Midodrine
Cardiac Pacing for VVS
- Patients ≥ 40 with highly
symptomatic VVS
- Documented symptomatic
asystole > 3s
- Documented asymptomatic
asystole > 6s
- Tilt-table induced asystole >
3s or HR < 40 bpm for > 10s
https://t.me/medicina_free
Category
Private Car Commercial
Driver
(Truck, Bus)
Syncope
Single/recurrent
vasovagal syncope
OK to drive
Reversible cause
(orthostatic,
dehydration) or
avoidable trigger
(micturition)
1 week 1 month
Single unexplained
syncope
1 week 12 months
Recurrent
unexplained
syncope
3 months 12 months
Tac hy/brady/device
syncope
Refer to respective recommendation
CCS 2023 Fitness to Drive Guidelines - Syncope
Major updates from previous guidelines:
• Restriction for vasovagal syncope in the
seated position has been removed, and
recurrent vasovagal syncope commented
on. Authors note that risk of vasovagal
syncope while driving is extremely low,
even in the setting of recurrent vasovagal
syncope.
• Reversible causes for syncope now have
the same recommendations as avoidable
triggers (previously were recommended
“treatment of underlying cause).
Commercial restriction for these causes is
now 1 month (previously 1 week).
CCS Fitness to Drive Guidelines 2023
https://t.me/medicina_free
Peripheral Arterial Disease
© Internal Medicine Review 2023
www.internalmedicinereview.ca
Key Resources:
• CCS 2022 Peripheral Arterial Disease Guidelines
MALE = Major Adverse Limb Events
https://t.me/medicina_free
Peripheral Arterial Disease
• PAD can manifest as intermittent
claudication, chronic limb threatening
ischemia or acute limb ischemia
• Diagnosis: ABI or TBI test of choice to
confirm diagnosis of PAD in patients with
symptoms
• Screening: adults age>50 with risk factors
(smoking, diabetes), even if asymptomatic
– No role for routine testing in asymptomatic
individuals without risk factors
– No role in also routinely screening for coronary
artery disease/carotid artery disease unless
they have symptoms of these conditions
– Guideline doesn’t specify frequency of screening
How to perform an ABI. N.B. requires continuous
wave doppler and blood pressure cuff:
https://youtu.be/5ux13-XjzgQ
CCS 2022 PAD
https://t.me/medicina_free
• Management:
– Smoking cessation : NRT, bupropion, varenicline, CBT
– Exercise program, walking therapy, foot care, wound therapy
– Diabetes management tight control may reduce MALE, including SGLT2i (↓
MACE, no increased amputation risk)
– Statins indicated
à
add on ezetimibe/PSCK9 inhibitor to target
– Hypertension per Hypertension Canada, <140/90, ACEi/ARB first line therapy
– Antithrombotic: indicated ONLY if symptomatic (i.e. not indicated if
asymptomatic)
• First line: ASA + low dose rivaroxaban 2.5 bid if high risk of ischemic events
– high-risk comorbidities such as polyvascular disease, diabetes, history of heart
failure, or renal insufficiency) and low bleeding risk
• Otherwise SAPT (clopidogrel > aspirin)
• Recommend against full dose anticoagulation + antiplatelet in stable
chronic PAD
CCS 2022 PAD
Peripheral Arterial Disease Management
https://t.me/medicina_free
• Revascularization indicated if symptoms affecting QoL and good targets to
revascularize:
– Method of repair depends on the location/anatomy/expertise available, requires team
approach, hybrid methods may be necessary
– AVOID endovascular repair in common femoral/femoral profundus
• Antithrombotic post revascularization:
– Elective endovascular repair: ASA + low dose rivaroxaban 2.5 bid first line
• DAPT (ASA + clopidogrel) if cannot receive low dose rivaroxaban
– Elective open repair: ASA + low dose rivaroxaban 2.5 bid
• If cannot tolerate then single antiplatelet OR VKA
– Emergent revascularization: (postop / at discharge)*:
• full dose anticoagulation [they don’t specify with what agent] + SAPT OR
• ASA + low dose rivaroxaban OR
• DAPT
*THESE ARE weak recommendation, no high quality studies here
surgeon usually directs management in real life
CCS 2022 PAD
Peripheral Arterial Disease Management
https://t.me/medicina_free
Summary
• Cardiac symptoms are often the presenting symptom of a noncardiac disease
– Always look for an etiology
• Know how to manage acute cardiac symptoms but always remember
to manage other contributing chronic risk factors (Cardiac and noncardiac)
• If conflicting guidelines, follow recent Canadian (CCS) guidelines and
do the safest thing
• Driving will always be an issue – know the restrictions
https://t.me/medicina_free
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