Syncope assessment — structured viva

Structured oral on syncope assessment: separating syncope from seizure and pseudosyncope, red-flag cardiac screening, orthostatic vitals technique, monitoring selection by episode frequency, counterpressure manoeuvres and tapers, pacemaker trial evidence from VPS II and ISSUE-3, and driving rules.

Prompt

The examiner opens: 'A young woman fainted at a wedding; her father wants every test under the sun. Talk me through your assessment — and where you will spend the health system's money.' The viva branches through classification, discriminators, red flags, investigations by frequency, treatment evidence and driving.

Stem

You are supervising a registrar. A 21-year-old student fainted twice in six months at hot crowded events with warning symptoms each time. ECG normal. Father requests an MRI of the brain "because something must be blocking blood flow". ^[7]

References8Show

[1]Connolly SJ et al. Pacemaker therapy for prevention of syncope in patients with recurrent severe vasovagal syncope: Second Vasovagal Pacemaker Study (VPS II). JAMA, 2003.PMID 12734133
[2]Sheldon R et al. Prevention of Syncope Trial (POST): a randomized, placebo-controlled study of metoprolol in the prevention of vasovagal syncope. Circulation, 2006.PMID 16505178
[3]Quinn J et al. Death after emergency department visits for syncope: how common and can it be predicted? Annals of emergency medicine, 2008.PMID 17889403
[4]Milton JC et al. Determinants of a positive response to carotid sinus massage and head-up tilt testing. Age and ageing, 2009.PMID 19818292
[5]Romme JJ et al. Effectiveness of midodrine treatment in patients with recurrent vasovagal syncope not responding to non-pharmacological treatment (STAND-trial). Europace, 2011.PMID 21752826
[6]Brignole M et al. Pacemaker therapy in patients with neurally mediated syncope and documented asystole: Third International Study on Syncope of Uncertain Etiology (ISSUE-3): a randomized trial. Circulation, 2012.PMID 22565936
[7]Costantino G et al. Syncope risk stratification tools vs clinical judgment: an individual patient data meta-analysis. Internal and emergency medicine, 2014.PMID 24862309
[8]Tomaino M et al. Physical counter-pressure manoeuvres in preventing syncopal recurrence in patients older than 40 years with recurrent neurally mediated syncope: a controlled study from ISSUE-3. Europace, 2014.PMID 24906609

Syncope assessment — structured viva

Stem

References8Show

[1]Connolly SJ et al. Pacemaker therapy for prevention of syncope in patients with recurrent severe vasovagal syncope: Second Vasovagal Pacemaker Study (VPS II). JAMA, 2003.PMID 12734133
[2]Sheldon R et al. Prevention of Syncope Trial (POST): a randomized, placebo-controlled study of metoprolol in the prevention of vasovagal syncope. Circulation, 2006.PMID 16505178
[3]Quinn J et al. Death after emergency department visits for syncope: how common and can it be predicted? Annals of emergency medicine, 2008.PMID 17889403
[4]Milton JC et al. Determinants of a positive response to carotid sinus massage and head-up tilt testing. Age and ageing, 2009.PMID 19818292
[5]Romme JJ et al. Effectiveness of midodrine treatment in patients with recurrent vasovagal syncope not responding to non-pharmacological treatment (STAND-trial). Europace, 2011.PMID 21752826
[6]Brignole M et al. Pacemaker therapy in patients with neurally mediated syncope and documented asystole: Third International Study on Syncope of Uncertain Etiology (ISSUE-3): a randomized trial. Circulation, 2012.PMID 22565936
[7]Costantino G et al. Syncope risk stratification tools vs clinical judgment: an individual patient data meta-analysis. Internal and emergency medicine, 2014.PMID 24862309
[8]Tomaino M et al. Physical counter-pressure manoeuvres in preventing syncopal recurrence in patients older than 40 years with recurrent neurally mediated syncope: a controlled study from ISSUE-3. Europace, 2014.PMID 24906609