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An 80-year-old man presents to the emergency department after an episode of loss of consciousness witnessed by his family. This happened while he was sitting in a chair, and it lasted for thirty seconds with a rapid recovery. There were no warning symptoms, convulsions, or neurological deficits afterward. The past medical history is significant for a myocardial infarction two years ago, prostatic hypertrophy, and recurrent episodes of loss of consciousness. The patient is on atorvastatin, metoprolol, enalapril, spironolactone, and tamsulosin. One month ago, a tilt-table study was normal. Echocardiogram showed moderately decreased left ventricular systolic function. An EKG in the emergency department shows a normal sinus rhythm. His blood pressure is 120/70 mm Hg while lying flat and 118/68 mm Hg while sitting up. His heart rate is 68/min and does not change with a shift in position. The rest of the physical examination is unremarkable. What is the best next step?
(A) CT scan of the head
(B) Holter monitor
© Carotid Doppler studies
(D) Electrophysiological studies
(E) No further evaluation is necessary
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1). His PMH of MI; 2) his loss of consciousness of 30'' with a rapid recovery. Any more?
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Holter monitor ! - sounds like an arrythmia is causing the syncope! clues - prev history of MI and the sudden rapid loss of consciousness and regain of consciousness ! very typical of syncope due to arrythmia .
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Also, Tilt table test is normal, exclude vasovagal
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well done to all of you
B) Holter monitor
Explanation:
Holter monitor or monitoring in a telemetry unit should be done first to see if the patient is having an arrhythmia as the cause of his syncope. Seventy-two-hour monitoring does not increase the yield in addition to that found on a 24-hour monitor. Cardiac electrophysiological studies are used to assess sinus node function, AV conduction, and to induce supra- or ventricular tachycardia. They are indicated in patients with episodes of syncope and a nondiagnostic ambulatory EKG. Disorientation, convulsions, aura, and incontinence would suggest a seizure. In that case, a CT scan of the head would be indicated. This patient had syncope and might have episodes of sustained ventricular tachycardia that might need the placement of an implantable cardiac defibrillator. For this reason, you cannot just ignore the episode and do nothing. Even without syncope, if the patient has had a previous infarction and an ejection fraction of
