Other Causes of Syncope

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Cerebrovascular disease. Syncope may occur with or without warning.
Transient neurologic signs such as unilateral weakness, ataxia, confusion,
slurred speech, numbness of an extremity, or facial asymmetry point to
obstruction to the cerebral blood flow. The syncopal episode is often
prolonged, and the postsyncopal period is characterized by confusion,
weakness, or focal neurologic signs.
Dizziness or syncope associated with upper arm exercise may lead to
diagnosis of a subclavian steal syndrome. This occurs when a severe
obstruction in the proximal subclavian artery allows shunting of blood away
from the cerebral circulation through the vertebral artery to the distal
subclavian artery. Upper arm exercise drops the vascular resistance distal
to the subclavian artery obstruction and enhances the "steal."
Epilepsy. Seizures may be difficult to distinguish from vasodepressor
syncope since both are often precipitated by fatigue and anxiety. An aura
often precedes the epileptic attack. Tonic or cIonic movements may be
witnessed. Loss of bladder or bowel control and biting of the tongue are
common in seizures but also occur with other forms of syncope. The
postictal period is usually prolonged, and the patient is confused or unable
to speak or move with ease.
Hyperventilation. Hyperventilation, a cause of dizziness and,
occasionally, syncope, is very common and a frequent reason for
emergency room visits. Early symptoms include tingling or numbness in
the hands, fingers, and around the mouth, dryness of the mouth, and a
feeling of smothering and apprehension, which may progress to severe
weakness, a sense of unreality, severe chest pain, dizziness, or syncope.
The patient usually breathes deeply, rapidly, and noisily in the later states.
However, hyperventilation may not be apparent. Unconsciousness is not
prolonged unless hyperventilation persists.
Idiopathic syncope. Even after careful historical analysis, the
mechanism of syncope may be unexplained in more than 50% of patients.

Intermittent Claudication
Claudication is produced when the blood supply to exercising muscle
is inadequate. This is usually due to significant atherosclerotic obstructio
to the lower extremities but may also be the result of arteritis, embolizati
or extrinsic compression of any vessel. Unless the obstruction is severe,
the limb is asymptomatic at rest. During exercise, the blood supply does
not match the metabolic demands of the tissue, and ischemia results. T
patient notices a cramp, charley horse, ache, or weakness that improves
with rest but recurs when exercise is resumed. The severity and location
of the problem is measured by asking the patient where the discomfort
occurs (foot, calf, thigh, or buttocks) and how much exertion is required
produce it: "How far can you walk without resting?" This can be quanti
as two-block claudication of the gluteal muscles and calves bilaterally. A
claudication progresses, the patient’s discomfort when walking increases
When occlusive disease involves the distal aorta at the iliac bifurcation,
the male patient may also reveal that he is unable to have or maintain a
erection. This is sometimes why the patient seeks medical advice.
When arterial disease is severe, ischemic discomfort may be present a
rest. The pain is described as boring, aching, intense, or steady. The
patient is usually restless, unable to sleep, or forced to dangle the leg ov
the side of the bed for slight relief.
Cyanosis
Although cyanosis is a physical finding and not a symptom, the patie
or a family member may notice that the skin is blue, dark, or dusky. Thi
information is extremely important in the infant, as it suggests the
presence of congenital heart disease with right-to-left shunting of the
underoxygenated blood into the arterial circulation. Cyanosis may be
apparent only when the child is crying, feeding, or exercising vigorously
Additional information is gained by asking if cyanosis was present at birt
or if it appeared later in life.
Cyanosis in the adult has less specific implications and may be due to
lung disease, pulmonary emboli, congenital heart disease, or abnormal
hemoglobins. Cyanosis with dyspnea should always suggest the presenc
of a large occluding pulmonary embolus. Cyanosis is not a sign of
congestive heart failure unless there is severe impairment of peripheral
capillary blood flow.

Common Symptoms of Cardiovascular Disease

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Chest Pain
Analyzing the many causes of chest pain to arrive at a correct etiology
can vex even the most astute clinician. Although there are numerous
causes of chest pain, the most important are angina pectoris, myocardial
infarction, pericarditis, pulmonary embolus, dissection of the aorta, chest
wall distress, and the pain of gastrointestinal disorders such as hiatal
hernia, esophageal disease or spasm, cholecystitis, pancreatitis, and
peptic ulcer distress.
The features of angina pectoris are described below in detail by using
the seven basic properties that separate angina pectoris from other
causes of chest pain. The distinguishing features of other causes of
chest pain are also discussed.
Angina Pectoris
In 1772, William Heberden described the clinical disorder he called
angina pectoris:
But there is a disorder of the breast marked with strong and
peculiar symptoms, considerable for the kind of danger belonging
to it, and not extremely rare, which deserves to be mentioned
more at length. The seat of it, and sense of strangling, and
anxiety with which it is attended, may make it not improperly be
called angina pectoris.
They who are afflicted with it, are seized while they are walking
(more especially if it be uphill, and soon after eating) with a
painful and most disagreeable sensation in the breast, which
seems as if it would extinguish life, if it were to increase or to
continue; but the moment they stand still, all this uneasiness
vanishes.*
swallowing, on lying down, and with movement, as well as containment of
pain when leaning forward or breathing shallowly, is almost diagnostic.
Radiation of the pain to the left trapezial ridge or scapula and awareness
that the intensity of the pain coincides with the heartbeat is characteristic
but not always present. The pain may be sudden or gradual in onset and
may fluctuate from mild to severe. Relief of the pain with steroids but not
with narcotics is typical. Surprisingly, some patients may have pericarditis
but not experience any chest discomfort.
Pulmonary Emboius
A large pulmonary embolus that produces infarction of the lung is
usually easily diagnosed by the sudden onset of sharp, pleuritic chest
pain, dyspnea, hemoptysis, cyanosis, and tachycardia. More commonly,
pulmonary emboli do not result in pulmonary infarction and may provide a
diagnostic dilemma. The diagnosis of pulmonary emboli should be
considered if there is pleuritic pain, unexplained dyspnea (particularly if
the dyspnea is acute and episodic), atrial arrhythmias, cyanosis,
tachycardia, fever, or congestive heart failure.
The diagnosis is strongly supported by the occurrence of hemoptysis,
which is so infrequent, however, that its absence should not alter the diag-
nosis. Since pulmonary emboli usually occur in the setting of venous injury,
venous stasis, or alteration of blood coagulation, questions should be directed
to precipitating causes. The following information should be obtained:
Prior history of pulmonary emboli
Presence of leg or calf tenderness
History of heart, lung, or blood disease
Recent surgery (particularly hip surgery), pregnancy, trauma, bed rest, or
long car trip
Use of oral contraceptives
Use of constricting girdle or garter
Occupation (prolonged standing)
Presence of varicose veins or previous vein stripping
By realizing that pulmonary emboli occur in certain settings, particularly
in hospitalized patients, and that their clinical presentation is rarely classic,
the clinician may be able to make the diagnosis.
Hyperventilation. Dyspnea related to anxiety and attendant hyperventi-
lation is very common and may provide a thorny differential diagnosis,
particularly because hyperventilation often causes chest discomfort
simulating angina. Patients with breathlessness due to hyperventilation
often describe their symptoms as "The air doesn’t go all the way down..."
or "1 can’t get a full breath." The patient should be carefully observed for
signs of sighing, swallowing of air, and anxiety, and should be asked about
other symptoms of hyperventilation such as tingling or numbness in the
hands ("falling asleep") or around the mouth, dryness of the mouth, and
dizziness. When anxiety is associated with organic heart or lung disease,
determining the major contributing cause of the dyspnea may be perplexing.
Dizziness and Syncope
The symptom of dizziness may cover a multitude of sensations,
including giddiness, a fainting feeling, temporary confusion, unsteadiness,
or vertigo. The patient may substitute other descriptions such as blacking
out, swimming in the head, graying of vision, lightheadedness, or falling-
out spells. Vertigo, a spinning sensation, must be carefully differentiated
from dizziness. The term "syncope" implies a temporary loss of
consciousness and postural tone that may or may not be preceded by
dizziness. An episode of dizziness and temporary loss of postural tone
without complete loss of consciousness is referred to as "near syncope."
Since the physician rarely has the opportunity to observe the episode of
syncope, the diagnosis is almost always based on a history provided by the
patient or a witness to the event. The following questions may be useful:
Did you feel as if you would faint, or was the sensation more like spinning
or vertigo?
What was the location and time of the attack? Did it occur more than once?

The Basic Structure of History Taking

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Ideally, ample time should be available to explore the medical history in
depth and in a relaxed manner. If time is short or the patient is too ill or
confused to be questioned at length, a limited interview, focused on the
immediate problem, is desirable. Later, as the patient improves, the history
can be completed.
The conversation might be initiated by asking the patient, "Tell me about
yourself." This friendly opening demonstrates that the physician is genuinely
interested in the person, not the disease. As Sir William Osier, the father of
American medicine, stated, "It is more important to know what sort of
patient has a disease than what sort of disease a patient has." The patient
should then be asked about his or her most important concerns and
current symptoms. At the outset, the physician encourages a spontaneous
flow of information with open-ended questions such as "Tell me about your
chest discomfort;’ After the patient has elaborated on his or her problem,
the physician can then follow up with more direct questions that favor or
dismiss a specific diagnosis: "Did the pain worsen with activity?"
The physician should be careful to avoid courtroom-type questions that
lead to premature closure of the subject and erroneous conclusions. The
experienced interviewer encourages the spontaneous flow of information
with comments such as "Go ahead;’ "mm-hmm," "Yes," "1 see," "What
else?" and "Tell me more." This technique, known as passive listening, is
enhanced by nonverbal communication such as open and receptive
posture, eye contact, and head nodding.
The physician should appear interested, sympathetic, and nonjudgmental
even if the patient becomes upset or hostile. If the patient becomes angry,
it may be helpful to say, "You seem upset." By actively listening to the
underlying feeling in the message and relaying this feeling back to the
patient, the physician demonstrates concern and understanding. For
example, the patient may say, "1 have a minor chest pain, but my wife
insists that you check out my heart." The physician might respond, "It’s
alarming to think that your chest pain could be due to a heart condition."
is important to recognize emotional and psychological overtones and their
implications. Revealing information may be obtained by asking, "What do
you think is wrong with your health?" The physician should also be alert
the possibility that the patient’s most distressing symptoms may not be
due to the most serious problem or that the patient may not be willing to
acknowledge certain potentially serious symptoms such as chest pain.

Symptoms
Do you experience:
chest discomfort or pain?
shortness of breath during moderate exertion?
shortness of breath when recumbent?
swelling of your ankles?
dizzy spells?
fainting spells?
palpitations, skipped heartbeats, or a racing heart?
significant unexplained fatigue?
coughing at night?
coughing up blood?
cramps or pain in your calves, thighs, or hips while walking that is
relieved by rest?
Do you:
have to elevate your head with more than one pillow to breathe
comfortably at night?
have to arise several times during the night to urinate?
have tender or swollen calves?
have varicose veins?
These questions should effectively screen for the presence of heart
disease that is producing physiologic impairment. When chest pains and
palpitations are excluded, the symptoms are traceable to secondary effects
of heart disease on other organs, particularly the lung, brain, kidney, and
blood vessels. If the patient answers any question affirmatively, the
symptom should be explored in more detail, using the approach outlined
in the previous chapter.
Etiology
The clinician should try to establish an etiology by asking questions
directed to known causes of cardiovascular disease. The scope and
number of questions are tailored to the patient, based on symptoms, prior
illnesses, physical findings, and other information gathered.