IBHRE Syncope and Autonomic Disorders — Questions and Answers

Question 1: What is the most common type of syncope in the general population?

Vasovagal syncope (Correct answer)
Cardiac syncope
Orthostatic hypotension
Carotid sinus syncope

Correct answer: Vasovagal syncope

Vasovagal (neurally mediated) syncope accounts for approximately 50% of all syncope cases and is the most prevalent form.

Question 2: Orthostatic hypotension is defined as a sustained reduction in systolic blood pressure of at least how many mmHg within 3 minutes of standing?

10 mmHg
20 mmHg (Correct answer)
30 mmHg
40 mmHg

Correct answer: 20 mmHg

Orthostatic hypotension requires a drop of ≥20 mmHg in systolic BP or ≥10 mmHg in diastolic BP within 3 minutes of standing.

Question 3: The cardioinhibitory type of vasovagal syncope is primarily characterized by:

Significant bradycardia or asystole with minimal hypotension (Correct answer)
Hypotension with little or no bradycardia
Both equal bradycardia and hypotension
Tachycardia followed by sudden loss of consciousness

Correct answer: Significant bradycardia or asystole with minimal hypotension

Cardioinhibitory vasovagal syncope is defined by predominant bradycardia or asystole with relatively preserved blood pressure until near loss of consciousness.

Question 4: Carotid sinus hypersensitivity is diagnosed when carotid sinus massage produces a ventricular pause of at least:

2 seconds
3 seconds (Correct answer)
4 seconds
5 seconds

Correct answer: 3 seconds

A ventricular pause of ≥3 seconds during carotid sinus massage defines the cardioinhibitory form of carotid sinus hypersensitivity.

Question 5: POTS (Postural Orthostatic Tachycardia Syndrome) is defined by a heart rate increase of at least how many beats per minute upon standing within 10 minutes, without orthostatic hypotension?

20 bpm
30 bpm (Correct answer)
40 bpm
50 bpm

Correct answer: 30 bpm

POTS requires an increase in heart rate of ≥30 bpm (or HR ≥120 bpm) within 10 minutes of standing without a concurrent drop in blood pressure ≥20 mmHg.

Question 6: Which alpha-1 adrenergic agonist is used to treat neurally mediated syncope and orthostatic hypotension by increasing peripheral vascular resistance?

Fludrocortisone
Midodrine (Correct answer)
Metoprolol
Pyridostigmine

Correct answer: Midodrine

Midodrine is a selective alpha-1 agonist that raises peripheral vascular resistance and venous return, reducing syncope recurrence and has a Class IIa recommendation for vasovagal syncope.

Question 7: The vasodepressor type of vasovagal syncope is primarily characterized by:

Significant bradycardia without meaningful hypotension
Hypotension with little or no bradycardia (Correct answer)
Asystole lasting more than 3 seconds
Tachycardia as the dominant feature

Correct answer: Hypotension with little or no bradycardia

Vasodepressor syncope is defined by predominant hypotension due to peripheral vasodilation, with heart rate decreasing by less than 10% of peak value.

Question 8: In the VASIS (Vasovagal Syncope International Study) classification, Type 2B vasovagal syncope is characterized by:

Cardioinhibitory response without asystole
Cardioinhibitory response with asystole ≥3 seconds (Correct answer)
Pure vasodepressor response
Mixed equal bradycardia and hypotension

Correct answer: Cardioinhibitory response with asystole ≥3 seconds

VASIS Type 2B is defined as a cardioinhibitory response with asystole of ≥3 seconds, which may favor pacemaker implantation in selected patients.

Question 9: The standard tilt table test is typically performed at what upright angle?

45 degrees
60 degrees
70 degrees (Correct answer)
90 degrees

Correct answer: 70 degrees

The Westminster protocol and most international guidelines recommend a tilt angle of 70 degrees as the standard for evaluating neurally mediated syncope.

Question 10: Fludrocortisone reduces syncope primarily by:

Increasing heart rate through sympathetic stimulation
Increasing blood volume via renal sodium and water retention (Correct answer)
Decreasing peripheral vascular resistance
Blocking vagal efferent signals to the heart

Correct answer: Increasing blood volume via renal sodium and water retention

Fludrocortisone is a synthetic mineralocorticoid that promotes renal sodium retention and fluid expansion, increasing central blood volume and reducing orthostatic hypotension.

Question 11: Syncope occurring during exercise in a young patient should raise concern for which underlying condition?

Vasovagal syncope
Hypertrophic cardiomyopathy (Correct answer)
Orthostatic hypotension
Carotid sinus hypersensitivity

Correct answer: Hypertrophic cardiomyopathy

Exercise-induced syncope in young patients is a red flag for obstructive or arrhythmic cardiac causes, with hypertrophic cardiomyopathy being a leading concern.

Question 12: The autonomic response in vasovagal syncope involves activation of which reflex?

Hering-Breuer reflex
Bainbridge reflex
Bezold-Jarisch reflex (Correct answer)
Cushing reflex

Correct answer: Bezold-Jarisch reflex

The Bezold-Jarisch reflex, triggered by activation of cardiac C-fibers (mechanoreceptors) in the inferior left ventricular wall, causes reflex bradycardia and vasodilation.

Question 13: On an implantable loop recorder (ILR) in a patient with recurrent syncope, which finding best supports a neurally mediated (vasovagal) mechanism?

Sustained monomorphic ventricular tachycardia
Gradual progressive bradycardia leading to asystole coinciding with syncope (Correct answer)
Sudden onset complete AV block without preceding slowing
Rapid ventricular response during atrial fibrillation

Correct answer: Gradual progressive bradycardia leading to asystole coinciding with syncope

A gradual progressive sinus bradycardia followed by asystole during spontaneous syncope on ILR is the hallmark ILR pattern of neurally mediated syncope.

Question 14: POTS is most commonly seen in which demographic group?

Elderly men over age 65
Young women between ages 15 and 50 (Correct answer)
Middle-aged men between ages 40 and 60
Pre-pubertal children under age 10

Correct answer: Young women between ages 15 and 50

POTS predominantly affects young women in the second through fourth decades of life, with a female-to-male ratio of approximately 5:1.

Question 15: Which of the following is an example of situational reflex syncope?

Syncope upon standing from a seated position
Micturition syncope (Correct answer)
Syncope during sustained exercise
Syncope due to arrhythmia onset

Correct answer: Micturition syncope

Micturition syncope is a form of situational reflex syncope triggered by specific physiological acts such as urination, defecation, coughing, or swallowing.

Question 16: An implantable loop recorder (ILR) is most appropriately indicated for:

Patients with daily syncope episodes on telemetry monitoring
Patients with recurrent unexplained syncope after a complete initial evaluation (Correct answer)
Patients with typical vasovagal syncope and clear triggers
Patients with syncope and known sustained VT on prior Holter

Correct answer: Patients with recurrent unexplained syncope after a complete initial evaluation

ILR is indicated for unexplained recurrent syncope where standard non-invasive tests have been inconclusive, allowing long-term ECG monitoring during spontaneous episodes.

Question 17: Neurogenic orthostatic hypotension is commonly associated with which of the following conditions?

Essential hypertension
Parkinson's disease (Correct answer)
Hyperthyroidism
Mitral valve prolapse

Correct answer: Parkinson's disease

Parkinson's disease and related synucleinopathies (e.g., multiple system atrophy) cause central and peripheral autonomic neurodegeneration, leading to neurogenic orthostatic hypotension.

Question 18: The EGSYS (Evaluation of Guidelines in Syncope Study) score is primarily used to:

Assess functional severity of heart failure
Predict the probability of a cardiac (arrhythmic) cause of syncope (Correct answer)
Guide selection of antiarrhythmic drug therapy
Determine candidacy for cardiac resynchronization therapy

Correct answer: Predict the probability of a cardiac (arrhythmic) cause of syncope

The EGSYS score uses clinical variables (palpitations, ECG abnormalities, structural heart disease, absence of vagal triggers) to predict the likelihood of cardiac syncope and guide risk stratification.

Question 19: Physical counterpressure maneuvers (PCMs) such as leg crossing with muscle tensing and handgrip are recommended as first-line treatment for:

Syncope due to ventricular tachycardia
Prodromal vasovagal syncope with warning symptoms (Correct answer)
Syncope due to complete AV block
Unexplained syncope without prodrome

Correct answer: Prodromal vasovagal syncope with warning symptoms

PCMs increase venous return and cardiac output during the prodromal phase of vasovagal syncope, aborting or delaying the syncopal episode without pharmacologic side effects.

Question 20: An HV interval of 70 ms or greater found during an electrophysiology study in a syncope patient is significant because it indicates:

Normal His-Purkinje conduction
Significant infranodal conduction disease increasing risk of high-degree AV block (Correct answer)
Accessory pathway-mediated tachycardia
Sinus node dysfunction

Correct answer: Significant infranodal conduction disease increasing risk of high-degree AV block

An HV interval ≥70 ms reflects markedly prolonged His-Purkinje conduction and is a strong predictor of spontaneous high-degree or complete AV block, guiding pacemaker implantation.

Question 21: Which of the following lifestyle modifications is a cornerstone of management for patients with POTS?

Fluid restriction and low-sodium diet to reduce cardiac preload
High fluid intake (2–3 L/day), high sodium diet, and compression garments (Correct answer)
Strict bed rest to minimize orthostatic stress
Elimination of all aerobic exercise to prevent tachycardia

Correct answer: High fluid intake (2–3 L/day), high sodium diet, and compression garments

Increasing fluid and sodium intake expands intravascular volume, while compression garments reduce venous pooling in the lower extremities, together reducing POTS symptoms.

IBHRE Syncope and Autonomic Disorders

What is the most common type of syncope in the general population?

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