Syncope due to reflex affecting heart

Vasovagal syncope

It  is a very common cause of dizziness or syncope that  is characteristically seen in response to the following.

• Fear
• Sudden emotional stress
• Anxiety
• Physical or mental exhaustion
• Pregnancy 
• Anaemia. 

Vasovagal syncope is always preceded by warning symptoms such as nausea. weakness, sweating, epigastric discomfort, blurred vision, headache, tinnitus, difficulty  in concentrating, sighing and dizziness.

The heart rate decreases, and the patient appears pale. The syncope is transient,and  last a few seconds to a few minutes, and this may be prevented by immediately lying down. Rarely, this type of syncope can occur when the patient is recumbent.

Orthostatic hypotension
Orthostatic hypotension produces dizziness on arising or after prolonged standing and this can be related to reduction  in effective blood volume, autonomic nervous system dysfunction, or rarely, to circulating vasodilator substances.

Causes are 

• Drugs-antihypertensive or antidepressant medications, vasodilators, and beta blockers
• Diabetic autonomic neuropathy
• Anaemia
• Low blood volume
• Large varicose veins
• Pregnancy
• Addison's disease (rare cause)
• Secondary hypertension-pheochromocytoma.

Hypersensitive carotid sinus
It is suspected when the patient describes dizziness or syncope after hyperextension of the neck, turning of the head, or pressure over the area of the carotid sinus from a necktie or during shaving. The syncope is evanescent, with rapid and complete recovery.

What is Dyspepsia?

Dyspepsia is a term to denote a variety of alimentary symptoms arising form upper gastrointestinal tract.
Symptoms  includes 

• Upper abdominal pain ± related to food
• Heart burn, regurgitation, water brash
• Anorexia, nausea, vomiting
• Early repletion and satiety after meals
• Flatulence, belching and bloating.

Causes of dyspepsia
Organic dyspepsia
Functional dyspepsia
Organic causes of dyspepsia

• Peptic oesophagitis
• Peptic ulcer
• Upper GI malignancy
• Hepatobiliary disease
• C/c pancreatitis
• Other system disorders - CRF, CHF etc.
• Drugs - NSAID, corticosteroids
• Alcoholism, pregnancy

Functional dyspepsia [nonulcer dyspepsiaI
It is due to motor dysfunction of upper gastrointestinal tract mediated by neurohumoral mechanism
What are the Alarm features in Dyspepsia

• Weight loss
• Anemia
• Vomiting
• Hematemesis
• Melaena
• Dysphagia
• Palpable abdominal mass.

Importance of past history in GIT

Past history is very important in gastrointestinal system

• History of Jaundice indicate viral hepatitis
• Drug intake - history of drug intake such as rifampicin. INH. anabolic steroids pills are risk factors for jaundice .NSAID intake for melena  or history of any herbal remedies
• Blood transfusion or transfusion of any blood products (viral hepatitis C. D and G).
• Recent tattooing or acupuncture: Drug abuse.to rule out viral hepatitis
• Alcohol consumption predispose to cirrhosis
• Tuberculosis can cause ascites due to tuberculous peritonitis.
• Haematemesis or melena (peptic ulcer, ruptured oesophageal varices, gastric malignancy)-
• Fever seen in tuberculosis, hepatocellular failure
• Haematochczia occur due to lower G. 1. malignancy. haemorrhoid

Hiccup – A diagnostic approach

Hiccup is caused by excitation of the phrenic reflex arc or by suppression of higher centers by central lesions or metabolic abnormalities. The sound is produced by a spasm of the inspiratory muscles that is abruptly terminated by glottis closure.

Recurrent or intractable hiccups should prompt a more thorough investigation. Hiccup with dysphagia suggests esophageal cancer, achalasia, or hiatal hernia.

Following are the causes of hiccup

• Benign
• Drugs
• Vagal stimulation
• Post-operative
• Pneumonia
• Subdiaphragmatic abscess
• Pericarditis
• Uremia
• Central
• Hysterical
• Splenic infarction
• Thoracic aortic aneurysm
• Liver metastasis
• Lung cancer
• Esophageal cancer
• Diagnostic Approach

Benign causes of hiccup

Self-limited hiccups occur in an healthy patient and it may be initiated by laughter or by gastric distension due to overeating or aerophagia.

Drugs producing hiccup

Alcohol, general anesthesia, barbiturates, benzodiazepines, dexamethasone, and methyldopa  can produce causes.

Vagal stimulation

A foreign body in contact with the tympanic membrane of ear can irritate the auricular branch of the vagus. Pharyngitis, laryngitis, or neck tumors can stimulate the recurrent laryngeal branchto produce hiccup.

Post-operative hiccup

Hiccups may be the result of general anesthesia itself or of diaphragmatic irritation with upper abdominal surgery.

Pneumonia

Hiccups are caused by inflammation  of diaphragm so there is usually pleuritic chest pain in the setting of cough, fever, and a pleural rub.

Subdiaphragmatic abscess

Suspect with abdominal pain which radiates to the shoulder and is associated with fever and localized upper abdominal tenderness.

Pericarditis

It is marked by chest pain relieved by leaning forward, and a two-or three-component friction rub, especially in the setting of myocardial infarction.

Uremia

The uremia is usually severe enough to cause a metabolic encephalopathy with asterixis.

Central

These hiccups are recognized by concomitant neurological findings. The most common central nervous system causes are encephalitis, brainstem tumor, basilar meningitis, and multiple sclerosis.

Hysterical hiccup

This type of  hiccup stops during sleep.

Splenic infarction

Hiccups accompany acute left upper quadrant abdominal pain. There is an embolic source, such as atrial fibrillation, endocarditis, or sickle cell anemia.

Thoracic aortic aneurysm

Otherwise  asymptomatic unless there is a dissection.

Liver metastasis

Suspect metastases if a primary cancer is known, but hiccups may be the presenting symptom. A firm mass is palpable in the right upper quadrant.

Lung cancer

Mediastinal adenopathy impinges on the phrenic nerve. Smoking history and hemoptysis are important clues.

Esophageal cancer

A tumor in the distal one-third of the esophagus is suggested by hiccups associated with dysphagia

Causes of chestpain in clinical practise

Types of chest pain observed in clinical practise are:
Restrosternal pain
Pleuritic pain
Acut onset chest pain
Chest pain with dyspnea 
Causes of chest pain with circulatory collapse or syncope

• Acute myocardial infarction.
• Tension pneumothorax.
• Pulmonary' thromboemlxilism
• Dissectlon of aorta.
• Cardiac tamponade.
• Acute pancreatitis.
• Upper gastro intestinal bleeding.

Causes of Retrosternal chest pain

Retrosternal chest pain  causes are given below

• Ischaemic heart disease.
• Oesophagitis or diffuse oesophageal spasm.
• Acute dry percardltis.
• Acute mediastinitis.
• Diaphragmatic hernia.
• Aneurysm of the aorta.
• Dissecting aneurysm.
• Psychogenic.

Causes of upper retrosternal Pain

It is a momentary pain which increases in intensity on coughing and subsides when the cough becomes productive. This is seen in acute tracheitis.

Mid or Lower Retrosternal Pain in mediastinal disease

Character resembling cardiac pain, radiate to neck and arms, unrelated to exertion.

This pain is constrictive in character and may be present in:

• Acute mediastinitis
• Mediastinal tumour
• Mediastinal emphysema
• Reflux esophagitis
• Achalasia cardia.

Causes of chest pain with breathlessness :

Following are the causes of chest pain with breathlessness

• Spontaneous pneumothorax.
• Acute myocardial infarction-Occurs in middle aged or aged persons ,characterised by  retrosternal pain with radiation to left hand, associate with  drenching sweat and shock. Breathlessness with signs of heart failure may occur.
• Acute pulmonary thromboembolism - Sudden onset of chest pain  with dyspnoea, haemoptysis and circulatory collpase develop. Tachycardia, right ventricular gallop rhythm, loud P2 are the clinical sign present.There is  normal resonant note on percussion over the chest. History of prolonged recumbency or signs of thrombophlebitis may be noted.
• Dissection of aorta -  Abrupt onset of chest pain with dyspnoea  and will mimick acute myocardial infarction with pain referred to the back. There is discrepancy between carotid pulses difference in BP in two arms, arrhythmia and features of acutely developing aortic regugitation. Dissection  of aorta occur more commonly in  Marfans  syndrome, hypertension, coarctation  and pregnancy
• Acute dry pleurisy (specially from consolidation) - Dyspnoea is not so common in this situation but chest pain is present. Pleural Friction rub is audible and no sign of pneumothorax can be detected.
• Massive collapse of the lung -There will be history of aspiration of foreign body .Mediastinalshifting is noted towards the side of collapse. Impaired resonance note on percussion. Breath sound is diminished vesicular or absent.
• H/O trauma can also produce chest pain with dyspnea. Point of tenderness may be detected. Normal resonant note on percussion.Typical findings of pneumothorax are lacking.
• Psychogenic condition can also produce chest pian with dyspnea

What are the causes of acute chest pain?

The causes of acute chest pain are the following

• Ischaemic heart disease (HID), ie. angina pectoris or acute myocardial infarction: aortic stenosis.
• Acute dry pleurisy due to any cause (tuberculosis, pneumonia commonly)
• Spontaneous pneumothorax.
• Diffuse oesophageal spasm (may be food-related) : gastro-oesophageal reflux disease.
• Acute pulmonary thromboembolism, tracheobronchitis, mediastinilis.
• Abscess, furuncle on the chest wall/myositis/fibrositis.
• Trauma to the chest wall, eg. rib fracture.
• Costoeondritis (Tietzes syndrome)
• Malignant deposits on the ribs, multiple myeloma.
• Acute dry percarditis.
• Intercostal myalgia (Bornholm disease—intercostal muscle involvement by Coxsackie  virus infection).
• Herpes zoster on the chest wall.
• Dissection of ascending aorta.
• Anxiety states /psychogenic  (cardiac neurosis)
• Abdomina disorders like hiatal hernia ,gall bladder stones, acute  pancreatitis, splenic flexure syndrome

What is palpitation?

Palpitation is defined as an unpleasant awareness of forceful, arrhythmic or rapid beating of the heart.
What is the mechanism of palpitation?

• Increase in the rate of contraction
• Increase in the force of contraction
• Change in the rhythm of contraction

Clinical  types of palpitation
Clinically two types of palpitation is present
Exertional palpitation - with organic heart disease, anemia etc.
Paroxysmal palpitation - episodes of palpitation at rest and non-exertional

• Fast, chaotic irregular palpitation in - atrial fibrillation
• Fast, regular palpitation in - paroxysmal tachyarrhythmia PSVT and VT

Paroxysmal supraventricular tachycardia (PSVT) is characterized by abrupt onset and abrupt offset that last for several minutes with fatiguability and followed by Polyuria.
Patient should try to replicate the rhythm of palpitation by tapping on a table to know is it a regular or irregular rhythm.
Skipped beat is flopping sensation due to atrial extra systole or ventricular extra systole
The causes of palpitation can be cardiac and non cardiac
Cardiac causes of palpitation are
Valvular heart disease

• Aortic regurgitation
• Mital regurgitation
• Tricuspid regurgitation
• Mitral stenosis 

Congenital heart disease

• Atrial septal defect
• Ventricular septal defect
• Patent ductas artenosus

Extrasystoles-Atrial, ventricular
Tachyarrhythmias Atrial, ventricular Paroxysmal atrial tachycardia
Atrial fibrillation.
Brady arrhythmia
Noncardiac causes of palpitation are
Hyperkinetic circulatory states such as

• Severe anemia
• Thyrotoxicosis
• Arteriovenous shunt
• Anxiety
• Pyrexia

Drugs can cause palpitation they are :

• Sympathomemetic
• Vasodilators 

Non organic causes are 

• Excessive smoking
• Commonest cause of palpitation is anxiety
• Idiopathic Prolonged anxietyr state (Soldier's heart, neurocirculatory asthenia. Da Costa's syndrome)
• Cardiac neurosis
• Haemorrhagic coma

Others are 

• Hypoglycemia 
• Pheochromocytoma,
• Thyrotoxicosis
• Psychogenic

Stridor and its causes

Inspiratory dyspnea occurring with upper airway obstruction should be identified promptly for the immediate relief of obstruction; otherwise it may endanger the life,It is seen in

• Angioedema
• Ludwig's angina
• Laryngeal diphtheria
• Foreign body

What is paroxysmal nocturnal dyspnoea?

PND is the sudden development of dyspnoea during the early hours of night occurs two three hours after retiring to bed. The patient awakens from sleep due to failing of severe suffocation and choking sensation. After getting up from bed the patient with either sits in bed with legs hanging by the side of bed or may rusts to the open window with the hope that coal air will relieve his symptoms.
This may be accompanied with dry repetitive cough due to interstitial oedema. Where the alveate are free of oedema.
This attack may progress and severe sweating can occur along with dyspnoea and subsides in 30 minutes. Sometimes it may progress to acute pulmonary oedema.
Significance of PND
PND occur due to acute left heart failure can be LAF or LVF (LAF left atrial failure, LVF – left ventricular failure. Acute onset dyspnoea with wheeze and repetrated productive cough are seen in cardiac asthma. It is characterised by wheeze due to bronchospasm which is more in night. Acute pulmonary oedema is the severe stage of cardiac asthma with leaking of fluid into the alveolar.
Causes of PND
PND is caused by left atrial or left ventricular failure
Clinical examination findings in PND

• Patient is usually anxious and pale with sweating and an hunger
• Central cyanosis may be present
• Tachycardia is present
• Blood pressure may be high
• Jugular venous pressure is elevated 
• S3 gallop may occur
• Auscultation of lung filed reveal vescular breath sound with prolonged expiration. Rhonchi and legs may be heard.

Orthopnea and its mechanism

Orthopnea is dyspnea on lying flat
Mechanism of orthopnea
Increased venous return to the pulmonary vascular system on lying flat lead to pulmonary congestion decrease the  compliance of the lung.
Mechanical disadvantage of diaphragmatic movement due to viscera, in lying position.
The part of the lung lying below the level of heart is more in lying position, thus more  area of lung congestion.
These changes will be reversed in upright position; orthopnea is an important feature of Left heart failure and also observed in acute asthma, COPD and diaphragmatic paralysis.

Platypnoea and its causes

Platypnoea is dyspnoea which occurs only in the upright position.
Causes of platypnea

• Left atrial thrombus
• Left atrial tumours—myxomas
• Pulmonary arteriovenous fistula.

Features of Pericardial pain

Pericardial pain is a type of central chest pain for hours to days

It is relieved by sitting and leaning forward

This is aggravated by lying down.

What is hyperventilation?

Hyperventilation means deep rapid breathing as in

• Acidosis
• Upper brainstem lesion,
• Hypoxia
• Hysteria
• Salicylate poisoning.

Tachypnea is respiratory rate > 22/min.
Bradypnea is respiratory rate < 10/min.

Differentiation between pulmonary and cardiac causes of Dyspnoea

Dyspnoea due to pulmonary aetiology has the following features

• Cough with expectoration precedes dyspnoea.
• Wheeze or stridor.
• Pleuritic chest pain.
• Pyrexia.
• Seasonal variation.
• Weight loss.
• Cyanosis (++ or +++).
• Progression over many years.
• Response to oxygen, bronchodilalors.
• Absence of obvious cardiac disease.

Dyspnoea due to cardiac aetiology has the following features

• PND and orthopnoea.
• Dyspnoea precedes cough with expectoration.
• Associated angina, syncope, palpitation: hypertension.
• Rapid progression of symptoms.
• Little or no cyanosis {+).
• Response to diuretics and digoxin.
• Physical signs of cardiac disease.

What are the features of Aortic pain?

Aortic pain is due to dissecting aneurysm of aorta

Acute excruciating, tearing type of chest pain is felt by the patient

Site of pain depends on the site of dissection

Pain may radiate to back.

This may be added with features of ischemia elsewhere, like Ischemic stroke, acute paraplegia,ischemia of limbs.

What are the causes of Acute Dyspnea?

Severe dyspnea at rest is seen in patients with

• Acute leftventricular failure
• ARDS
• Acute exacerbation of asthma
• COPD
• Tension pneumothorax
• Massive pleural effusion
• Upper respiratory obstruction due to laryngeal edema/ angioedema
• Massive pulmonary embolism
• Foreign body in respiratory tract, irritant gas inhalation.

What is Unstable Angina?

The following three patient groups may be said to have unstable angina pectoris.

• Patients with new onset (< 2 months) angina that is severe and/or frequent (>) 3 episodes/day
• Patients with accelerating angina, that is, those with chronic stable angina who develop angina that is distinctly more frequent, severe, prolonged or precipitated by less exertion than previously.
• Those with angina at rest.
• When unstable angina is accompanied by objective ECG evidence of transient myocardial ischaemia, this is associated with critical stenosis in one or more epicardial coronary arteries in about 85%.

What are the causes of chest pain?

Chest pain is the  most important symptom in cardiovascular diseases.
It can be due to

• Cardiovascular origin
• Non-cardiovascular origin
• Cardiovascular causes of chest pain 
• Anginal pain, usually not < 1min, not > 20 min
• Pericardial pain
• Aortic pain.

Non-cardiovascular origin

• Chest wall pain
• Respiratory system - pleura, upper airway
• Mediastinum - oesophagus and other tissues
• Psychogenic.