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When an anxiety state is accompanied by faintness, the pattern of symptoms can often be reproduced by having the subject hyperventilate that is, breathe rapidly and deeply for 2 to 3 min This test may also be of therapeutic value, because the underlying anxiety tends to be lessened when the patient learns that the symptoms can be produced and alleviated at will simply by controlling breathing Most patients with tussive syncope cannot reproduce an attack by the Valsalva maneuver but can sometimes do so by voluntary coughing if severe enough Another useful procedure is to have the patient perform the Valsalva maneuver for more than 10 s (thus trapping blood behind closed valves in the veins) while the pulse and blood pressure are measured (see Tests for Abnormalities of the Autonomic Nervous System, Chap 26) In each of the aforementioned instances, the crucial point is not whether symptoms are produced but whether they reproduce the exact pattern of symptoms that occurs in the spontaneous attacks Other conditions in which the diagnosis is clari ed by reproducing the attacks are carotid sinus hypersensitivity (massage of one or the other carotid sinus) and orthostatic hypotension (observations of pulse rate, blood pressure, and symptoms in the recumbent and standing positions or, even better, with the patient on a tilt table) The tilt table test is now a regularly used procedure when the diagnosis of syncope is not evident from physical examination and routine studies such as electrocardiography (ECG), blood count, and bedside sphygmomanometry There is a distinct difference in the cardiovascular challenge imposed by a tilt table and that created by the simple act of standing up from a sitting or recumbent position, as discussed below It should be re-emphasized that, from the perspective of detecting an underlying autonomic failure, having the patient stand abruptly from a lying position and then recording the blood pressure every 30 to 60 s for up to 3 min is more informative than interposing a period of sitting between the lying and standing positions Patients with sympathetic failure of central or peripheral type, and those with hypovolemia will show a drop in blood pressure within 30 s; those with a propensity to re ex fainting may take much longer, or show no drop at all The measurement of beat-to-beat variation in heart rate is a simple but sensitive means of detecting vagal dysfunction, as described in Chap 26 Careful, continuous monitoring of the ECG in the hospital or by using a portable recorder may determine whether an arrhythmia is responsible for the syncopal episode A continuous cardiac loop ECG recorder (which continually records and erases cardiac rhythm) permits prolonged (a month or longer) ambulatory monitoring at reasonable cost The diagnostic yield from loop recording is much greater than that from Holter monitoring (Linzer et al) The signal-averaged ECG is reportedly a useful means of identifying individuals at risk for ventricular tachycardia as a cause of syncope (Manolis) Tilt-Table Testing There are two types of abnormal response to upright tilting: early hypotension (occurring within moments of tilting), which signi es inadequate sympathetic tone and baroreceptor function; and a delayed (several minutes) hypotension and syncope, which indicates a neurocardiogenic mechanism The normal response to an 60- to 80-degree head-up tilt for 10 min is a transient drop in systolic blood pressure (5 to 15 mmHg), a rise in diastolic pressure (5 to 10 mmHg), and a rise in heart rate (10 to 15 beats per minute) Abrupt and persistent declines in blood pres-.

Using the Call Chart Properties Dialog command (OPEN_ CHART _DIALOG), you can call the Chart Properties dialog box at run time for a Web application The parameter in Table 6-6 requires configuration within the process of setting up the command parameters when you insert the command For this first command, I will show you how to configure it The configuration process for the other commands in the list is very similar, so you can go through and experiment with this process on your own Go into the WAD and use the Call Chart Properties Dialog command to display the Chart Properties The initial step is to have a chart available, so we add a basic chart to this Web template, as shown next

sure of greater than 20 to 30 mmHg systolic and 10 mmHg diastolic and a drop (or failure to rise) of the heart rate are considered abnormal; often these ndings are associated with faintness and sometimes with syncope Although controversial, in some circumstances the infusion of the catecholamine isoproterenol (1 to 5 mg/ min for 30 min during head-up tilt) may be a more effective means of producing hypotension (and syncope) than the standard tilt test alone (Almquist et al; Waxman et al) It should be repeated that the presence of a delayed faint with tilting only demonstrates a proclivity to neurocardiogenic fainting, since it occurs in a proportion of individuals who have never fainted; it is not to be taken as incontrovertible evidence that a recent spell is explained by this mechanism

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Patients seen during the preliminary stages of fainting or after they have lost consciousness should be placed in a position that permits maximal cerebral blood ow, ie, with head lowered between the knees if sitting or preferably in the supine position with legs elevated All tight clothing and other constrictions should be loosened and the head and body positioned so that the tongue does not fall back into the throat and the possible aspiration of vomitus is avoided Nothing should be given by mouth until the patient has regained consciousness The patient should not be permitted to rise until the sense of physical weakness has passed and he should be watched carefully for a few minutes after arising As a rule, the physician sees the patient after recovery from the faint and is asked to explain why it happened and how it can be prevented in the future One should think rst of those causes of fainting that constitute a therapeutic emergency Among them are massive internal hemorrhage and myocardial infarction, which may be painless, and cardiac arrhythmias In an elderly person, a sudden faint without obvious cause must always arouse the suspicion of a complete heart block or other cardiac arrhythmia The prevention of fainting depends on the mechanisms involved In the usual vasodepressor faint of adolescents which tends to occur in circumstances favoring vasodilatation (warm environment, hunger, fatigue, alcohol intoxication) and periods of emotional excitement it is enough to advise the patient to avoid such circumstances In postural hypotension, patients should be cautioned against arising suddenly from bed Instead, they should rst exercise the legs for a few seconds, then sit on the edge of the bed and make sure they are not light-headed or dizzy before starting to walk Standing for prolonged periods can sometimes be tolerated without fainting by crossing the legs forcefully Alternatives should be found for medications that are conceivable causes of orthostasis Beta-adrenergic blocking agents, diuretics, antidepressants, and sympatholytic antihypertensive drugs are the common culprits In the syndrome of chronic orthostatic hypotension, special corticosteroid preparations such as udrocortisone acetate (Florinef) 005 to 04 mg/day in divided doses and increased salt intake to expand blood volume are helpful Recently the alpha1 agonist midodrine, beginning with 25 mg every 4 h and slowly increasing the dose to 5 mg every 4 to 6 h, has been used successfully in small studies, but this medication has the potential to worsen the situation and must be used with care Sleeping with the headposts of the bed elevated on wooden blocks 8 to 12 in high and wearing a snug elastic abdominal binder and elastic stockings are measures that often prove helpful Tyramine and monoamine oxidase inhibitors have given limited relief in some cases of Shy-.