Solving the Puzzle of Syncope Part. 1
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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