Presentation on Syncope, Fatigue and Peripheral Edema

1. Dr. Sujay Iyer
I year PG, General Medicine

2.  SYNCOPE
 FATIGUE
 PERIPHERAL EDEMA

3.  Syncope is the abrupt and transient loss of
consciousness associated with absence of
postural tone, followed by complete and
usually rapid spontaneous recovery.
 Although, syncope can be a harbinger of a
multitude of disease processes and can
mimic cardiac arrest, it is most often benign
and self-limting.

4.  Syncope is a common clinical problem.
 The Framingham Heart Study was one of the largest
epidemiological study that evaluated the incidence
and prognosis of syncope.
 822 of 7814 men and women (11%) were followed for
an average 17 years.
 Results:
◦ Increased with age. Sharp rise at age 70 years.
◦ Incidence, similar in men and women; with men more likely
to have a cardiac cause.
 Different studies suggest that one-third of
individuals are likely to have a syncopal episode
during their lifetime.
 3-5% of ER admissions are because of syncope.

5.  Cardiovascular disease is a major risk factor for
syncope.
 The incidence rate among participants of with
cardiovascular disease was almost twice (10.6%
vs 6.4%) that of participants without
cardiovascular disease in the Framhingham
cohort.
 Other risk factors:
◦ History of stroke
◦ History of TIA
◦ Hypertension
 Additional risk factors are: low BMI, increased
alcohol intake and diabetes.

6.  Determining the cause of syncope is
important for both prognostic and
therapeutic reasons.
 In general, vasovagal attacks are the most
common cause of syncope, followed by
cardiac etiologies.
 The cause is unknown in approximately, one-
third of patients.
 Patients with cardiac causes of syncope have
higher rates of sudden cardiac death.

7. REFLEX SYNCOPE (Neurally Mediated)
Vasovagal
Mediated by emotional distress (fear, pain, phobia, etc.)
Mediated by orthostatic stress
Situational
Cough, sneeze
Gastrointestinal stimulation (swallowing, defecation, visceral pain)
Post-Micturition
Post-Prandial
Post-Exercise
Others (laughter, weightlifting, etc.)
Carotid sinus syncope
Atypical forms

8. CARDIOVASCULAR SYNCOPE
Arrhythmias
Bradycardia:
• Sinus node dysfunction
• Atrioventricular conduction system disease
• Implanted device malfunction
Tachycardia:
• Supraventricular
• Ventricular
Drug-induced bradycardia and tachyarrhythmias
Structural Disease
Cardiac:
• Cardiac valvular disease
• Myocardial infarction
• Hypertrophic cardiomyopathy
• Cardiac masses ( atrial myxomas, tumors, etc.)
• Pericardial disease/ tamponade
• Congenital anomalies
Others: Pulmonary embolus, aortic dissection, pulmonary hypertension

9. SYNCOPE DUE TO ORTHOSTATIC HYPOTENSION
Primary Autonomic Failure
Pure autonomic failure, multiple system atrophy, Parkinson's disease with
autonomic failure, Lewy body dementia.
Secondary Autonomic Failure
Diabetes, amyloidosis, uraemia, spinal cord injuries
Drug-induced Orthostatic Hypotension
Alcohol, vasodilators, diuretics, phenothiazines, antidepressants
Volume Depletion
Hemorrhage, diarrhoea, vomiting, etc

10.  Syncope occurs due to global cerebral
hypoperfusion.
 Brain parenchyma depends on adequate
blood flow to provide a constant supply of
glucose, the primary metabolic substrate.
 Brain tissue cannot store energy in the form
of high-energy phosphates found elsewhere
in the body.
 Cessation of cerebral perfusion lasting only
3-5 seconds can result in syncope.

11.  Cerebral perfusion is maintained relatively
constant by an intricate and complex
feedback system involving:
◦ Cardiac output,
◦ Systemic vascular resistance
◦ Arterial pressure
◦ Intravascular volume status
◦ Cerebrovascular resistance
◦ Metabolic regulation
 Clinically significant defect in any of these
may cause syncope.

12.  Cardiac output can be diminished due to:
◦ Mechanical outflow obstruction
◦ Pump failure
◦ Arrhythmias
◦ Conduction defects
 Systemic vascular resistance can drop due to:
◦ Vasomotor instability
◦ Autonomic failure
◦ Vasovagal response
 Mean arterial pressure can decrease due to all
causes of hypovolemia.
 Medications can affect CO, SVR or MAP.

13.  Arrhythmias are the most common cardiac causes of
syncope.
 Arrhythmias lead to abrupt change in heart rate and the
blood pressure may precipitously decline, especially in an
upright position, causing transient loss of consciousness.
 They usually cannot be diagnosed as they are paroxysmal
and infrequent.
 In contrast to vasovagal or other causes of syncope,
arrhythmic syncope often occurs without warning.
 Tachycardias are usually more hemodynamically unstable
and are less well tolerated than bradycardias.
 Common arrhythmic causes of syncope: sinus bradycardia,
AV nodal block, sustained VT and SVT.

14.  Edema is defined as a palpable swelling
produced by expansion of interstitial fluid
volume.
 A variety of conditions are associated with the
development of edema, including heart
failure, cirrhosis and nephrotic syndrome.

15.  There are two basic steps involved in edema
formation:
◦ An alteration in capillary hemodynamics that favors
the movement of fluid from vascular space into
interstitium.
◦ The retention of dietary or intravenously
administered sodium and water by the kidneys.
 Edema doesnt become apparent until the
interstitial volume has increased by atleast
2.5 to 3 litres.

16. Capillary Hemodynamics
 The exchange of fluid between plasma and
interstitium is is determined by the hydraulic and
oncotic pressures.
 The relationship between the two has been described
by Starling’s Law:
◦ Net Flitration = Lps x (Delta Hydraulic pressure – Delta
Oncotic Pressure)
◦ ‘Lp’ is the unit of permeability of the capillary wall and ‘s’ is
the surface area available for fluid movement.
 Edema formation occurs when there is alteration of
capillary dynamics:
◦ Elevation in capillary hydraulic pressure
◦ Increased capillary permeability
◦ Lower plasma oncotic pressure.

17.  Heart failure can be produced by a variety of
disorders, including coronary artery disease,
hypertension, cardiomyopathies, valvular
disease and cor pulmonale.
 Edema in the different causes is due to:
◦ An increase in venous pressure (augmentation of
blood volume) that produces a parallel rise in
capillary hydraulic pressure.
◦ Renal sodium retention due to reduced perfusion of
kidneys.
 Site of edema accumulation is variable and
dependent upon nature of cardiac disease.

18.  Coronary artery disease, hypertensive heart disease and
left-sided valvular disease tend to preferentially impair
left ventricular function. As a result, these disorders
typically present with pulmonary but not peripheral
edema.
 Cor pulmonale is initially associated with pure right
ventricular failure, resulting in prominent edema of
lower extremities, and perhaps, ascites.
 Cardiomyopathies tend to produce equivalent
invovlement of both right and left ventricles, leading to
simultaneous onset of pulmonary and peripheral
edema.
 Peripheral edema is usually pitting (5 seconds), as it
reflects movement of interstitial fluid in response to
pressure.

20.  Fatigue is a subjective feeling of tiredness
which is distinct from weakness, and has a
gradual onset.
 Fatigue can be alleviated by periods of rest.
 Fatigue can have physical or mental causes.
 Prolonged fatigue is self-reported, persistent
fatigue lasting for at least one month,
whereas chronic fatigue lasts for six months.
 Chronic fatigue is a symptom of heart
disease.

21.  It is defined as extreme generalized edema
characterised by widespread swelling of the
skin due to effusion of fluid into the
extracellular space.
 It is usually caused by liver failure, renal
failure, right heart failure and severe
malnutrition.

22.  Increasing fatigue is a symptom of cardiovascular
disease.
 It occurs because less blood reaches the muscles
and the tissues due to reducing pumping ability
of the heart.
 The body diverts blood away from the less vital
organs.
 Causes:
◦ Congestive heart failure
◦ Coronary artery disease
◦ Valvular heart disease
◦ Cor pulmonale

23.  Autoimmune diseases (Celiac, Lupus, MS, Myasthenia Gravis, Sjorgen’s etc.)
 Blood disorders (Anemia & Hemochromatosis)
 Chronic Fatigue Syndrome
 Drug abuse including alcohol abuse
 Depression
 Eating disorders
 Endocrine diseases (Diabetes, Hypothyroidism)
 Fibromyalgia
 HIV
 Gulf war syndrome
 Infection diseases (Infectious Mononucleosis)
 IBS
 Leukemia or Lymphoma
 Physical Trauma
 Liver Failure
 Neurological disorders (Narcolepsy, Parkinson’s, Post-concussion syndrome)
 Stroke
 Sleep Disorders
 Uremia
 Medications (Lithium salts, Ciprofloxacin, Beta Blockers)

24.  Harrison’s Principles of Internal Medicine
 www.uptodate.com
 www.medscape.com