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Solving the Puzzle of Syncope Part. 1

September 26, 2017





High Yield Review - Syncope after Meals 

 Case: A 75 y/o female with a past medical history of diet controlled hypertension, comes in today to have her morning labs  collected and who has a complaint about several fainting episodes over the past few weeks. 


She describes that she has feelings of light headedness, 

and tunnel vision in the morning, afternoon, and evening times.


She recently fainted the other evening after participating 

in a pie eating contest


Another time of fainting was after wine tasting with friends. 


She said once she felt as if she was going to black out after

eating a bowl of fruit laying in a hammock, she 

checked her blood pressure at home and it was 90/70 mmhg  she

says she is usually 110/80 mmhg. 


Her vitals are 110/80 mmhg, 80 heart rate 

Orthostatic Blood pressure check:

Supine 116/80 mmhg, 79 heart rate

Standing: 110/80 mmhg 82 hear rate 


You do not hear a murmur on exam


EKG Shows  Normal Sinus rhythm, with prolonged PR > 200ms, 78 Heart rate. 


You have a suspicion for post prandial hypotension., and you advise her to eat small frequent meals, since her blood pressure is excellent you tell her to increase her salt and water intake, you suggest that she avoids consumption of high carbohydrate foods and decrease any alcohol intake.

You prescribe her compression stockings and advise

her to avoid physical exertion after meals. 


She comes back for a follow up and her symptoms have resolved and no other fainting episodes


What if 


What if she continued to have syncopal episodes?

- Then Rx octretotide for refractory cases of post prandial syncope / hypotension. 


Case Clues - Postprandial Syncope 

- She is  75 y/o /  Elderly 

- Diet controlled Hypertension : So this means she consumes low sodium ( ~ 2G Na ) 

- Symptomatic or fainting episodes Morning / Afternoon / Evening  or around the times of breakfast, lunch and dinner 

- Her PR is prolonged which is a first degree heart block, but with a normal ventricular rate 

- She had a recent syncopal event(s) after a pie ( high in sugar / carbs ) eating contest  and wine tasting 

- No murmur on exam ( so no Aortic stenosis )

- Probable Abnormal home orthostatic exam she checked her BP when she had symptoms she randomnly checked  90/70 mmhg ( Orthostatic BP is a decrease of Systolic BP of 20mmhg or more, and Diastolic BP 10 mmhg or more ) 

Know if for the Boards! 




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