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You are a junior doctor working in A&E when you are asked to see a 54 year old gentleman who has just arrived. Take a history, examine the patient, suggest appropriate investigations and formulate a management plan.

History

Presenting complaint

I was walking the dog today when I suddenly felt funny, the next thing knew I was on the floor and somebody passing by had called an ambulance.

What questions might be useful to elicit further detail surrounding the presenting complaint?

Did you have any symptoms before the collapse?

No I didn’t notice anything particularly out of the ordinary

 

Did you experience any palpitations or chest pain?

No I don’t believe so

 

Did you lose consciousness? How long for?

I definitely lost consciousness, but I’m not sure how long for, probably only 30 seconds or so

 

What were you doing immediately before the loss of consciousness?

I was walking across the sand dunes with the dogs

It was quite a sharp incline and I did run after the dog as he’d disappeared over the top of the dune and I was worried he’d run away

 

Did anyone witness the collapse?

Yes another dog walker came over, she called an ambulance

 

Did you have any incontinence?

No

 

Have you sustained any injuries / did you injure your head?

I must have banged my shoulder because it’s hurting, I think it hit a rock

I don’t think I’ve injured my head

 

Do you know where you are? What is today’s date? What is my job?

*Patient is orientated* GCS15

 

Have you had this happen before?

I’ve had a few faints in the past, not whilst walking the dogs though

I had one when I was getting out of the shower, the room was really hot and I started feeling nauseas then blacked out

 

What’s your usual exercise tolerance?

It’s decreased over the last year

I used to take the dogs out for at least an hour, often 2 hours

Now it’s more like 20 minutes maximum

 

Why are you not able to stay out longer?

Because I just don’t have the strength, I get tired much easier than I used too and often begin to feel quite short of breath

 

Any nausea or vomiting?

No

What else might be useful to gain further details about the nature of the patient's collapse?

COLLATERAL HISTORY

How did Mr Smith look when you arrived?

He was very pale when I got to him

 

Was he conscious when you arrived?

Not initially, he didn’t respond for the first 30 seconds

 

When he did regain consciousness was he orientated? 

He wasn’t confused, he was orientated

 

How quickly did he go from being unconscious to being orientated?

He recovered quickly, within 20 seconds he appeared fairly normal, just a little pale

 

Did you notice any jerking movements or tongue biting whilst he was unconscious?

He wasn’t jerking, he was just lying still and I didn’t notice him biting his tongue

What other questions might you ask to complete your history taking?

Past medical history
Pre-syncope / syncope – has the patient has previous symptoms of dizziness or loss of consciousness?

Seizures – is the patient known to have epilepsy?

Cardiac history – arrhythmias / myocardial infarction / hypertension

Malignancy – loss of consciousness / seizures can be the presenting symptom of primary brain malignancy or secondary intracerebral metastases

 

Medications

Regular medications?

  • Pay attention to any that might cause syncope e.g. antihypertensives
  • Anticonvulsant medication – has the patient been taking this reliably or missing doses?
  • Antiplatelets / Anticoagulants – important when considering intracranial haemorrhage 

Recreational drug use? – cocaine / amphetamines can cause loss of consciousness, seizures, arrhythmias and intracranial haemorrhage 

 

Family history

Seizures / Cardiac disease / Sudden death 

 

Social history

  • Living situation – where does he live and who with?
  • Alcohol intake 
  • Smoking status
  • Occupation

 

Systemic enquiry

  • Any other symptoms in other body systems? – weight loss / gain

Patient answer

“I take ramipril for my blood pressure but no other regular medication. I’ve had several episodes of dizziness over the last year or so as I said earlier. I’ve not had any heart attacks or other medical problems. I’ve never taken any recreational drugs!  There’s no diseases that run in my family and I live alone in a bungalow. I used to drink a few pints of beer a week, but I’ve stopped altogether now. I don’t smoke and I’m now retired.”

Examination

What specific examinations might be useful to carry out?
  • Cardiovascular examination
  • Respiratory examination
  • Neurological examination (Cranial nerves / Upper & lower limbs)
  • Musculoskeletal examination 

Cardiovascular examination

  • Pulse  – 65 bpm – slow rising in nature
  • BP –  150/120
  • CRT –  <2
  • Auscultation:
    • Ejection systolic murmur
    • Heard loudest over the sternum
    • The murmur can be heard radiating to the carotids

Respiratory examination

  • Equal air entry
  • No added sounds
  • Sats 98%
  • Respiratory rate – 16

 

Neurological examination

  • Cranial nerves intact
  • No upper or lower limb deficits

 

Musculoskeletal examination

  • Some bruising to the right shoulder, but normal range of motion.
  • Nil else of significance.

Investigations

What bedside investigations might be useful?
  • Basic observations – BP / Pulse / RR / Sats / Temp
  • Capillary blood glucose 
  • Blood tests – FBC / U&E / CRP / Troponin / Coagulation
  • 12 Lead ECG

Bedside investigation results

Basic observations

  • BP 150/120
  • Pulse 65 bpm
  • RR 16
  • O2 Saturation 98% on air
  • Temperature – 36.3°c

 

Capillary blood glucose  6.2 mmol/L

 

Blood tests

Blood results

 

ECG

LVH - Strain Pattern

What does the ECG show?
  • Rate – 75bpm
  • Sinus rhythm
  • Normal PR interval
  • Normal QRS duration
  • Normal QT interval

 

Left ventricular hypertrophy with strain pattern:

  • Increased R wave amplitude in left sided leads (I, aVL and V5-6)
  • Increased S wave depth in the right-sided leads (III, aVR, V1-3)
  • ST depression in the lateral leads (I, aVL and V5-6)
What does this image show?

Clear lung fields.

Cardiomegaly.

Differential diagnosis

What is your differential diagnosis?
  • Vasovagal syncope
  • Aortic stenosis
  • Hypertrophic cardiomyopathy
Which investigation would be useful in confirming a diagnosis?

Echocardiography 

A transthoracic echo is performed and demonstrates severe aortic stenosis with associated left ventricular hypertrophy.

Transthoracic echo

Transthoracic echo

Management

What management options are available for this patient?

Symptomatic patients require early surgical intervention because no medical therapy for aortic stenosis is able to improve outcome.

Medical therapy

Modification of atherosclerotic risk factors is strongly recommended. Aortic stenosis in the older age group should be seen as a strong risk for ischaemic heart disease:²

  • Statins
  • Antihypertensives – being careful not to induce hypotension
  • Smoking cessation and dietary advice

 

If the patient is unsuitable for surgical intervention:

  • Digoxin / Diuretics / ACE inhibitors – to provide symptomatic relief from heart failure symptoms
  • Maintenance of sinus rhythm is important – use antiarrhythmic drugs as required

Aortic valve replacement

Aortic valve replacement (AVR) is the definitive therapy for severe aortic stenosis (AS).

Operative mortality of AVR for AS:

  • 1-3% in patients < 70 years
  • 4-8% in older adults

Early valve replacement is strongly recommended for all symptomatic patients with severe AS who are suitable for surgery.

 

Transcatheter aortic valve implantation (TAVI)

TAVI is a recent development and provides a method of AVR which does not carry the same risks as surgical AVR mentioned above. 

 

What does TAVI involve?

TAVI can be performed under a general anaesthetic or under local anaesthetic with sedation, making it a consideration in patients who are unsuitable for surgical AVR.

TAVI involves the replacement of the aortic valve of the heart via the blood vessels (not requiring open heart surgery).  The replacement valve is delivered via one of several access methods: transfemoral (in the upper leg), transapical (through the wall of the heart), subclavian (beneath the collarbone) and direct aortic (through a minimally invasive surgical incision into the aorta).  The whole procedure occurs under fluoroscopy and echocardiography guidance.

 

Key points:

  • The procedure is less invasive and carries less risks than a surgical aortic valve replacement.
  • The procedure is of equal efficacy as surgical AVR in patients who are unsuitable for surgery.
  • As with any surgical procedure, there are associated risks which include major bleeding, stroke, arrhythmias, myocardial infarction, aortic dissection and residual aortic regurgitation.

 

Balloon valvuloplasty

This procedure involves widening of a stenotic aortic valve using a balloon catheter inside the valve. The balloon is inflated in an effort to increase the opening size of the valve and improve blood flow.

Current evidence supports the safety and efficacy of balloon valvuloplasty for aortic valve stenosis in adults and children.³

However, restenosis and clinical deterioration occur within 6-12 months in most patients.³

In adults the procedure is only used to treat patients who are unsuitable for surgery, due to the efficacy usually being short-lived.

References

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  1. By Nevit Dilmen (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 3. (0https://upload.wikimedia.org/wikipedia/commons/8/8c/Rad_1300124.JPG)
  2. Prasad Y, Bhalodkar NC; Aortic sclerosis–a marker of coronary atherosclerosis. Clin Cardiol. 2004 Dec;27(12):671-3.
  3. Balloon valvuloplasty for aortic valve stenosis in adults and children, NICE Interventional Procedure Guideline (2004)

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