What is the prioritized care for a 77-year-old patient with unheralded syncope, new left bundle branch block, moderate to severe aortic stenosis, and an abnormal head computed tomography (CT) scan showing a possible meningioma or chronic intracranial hemorrhage?

Prioritized Care for 77-Year-Old with Syncope, LBBB, Aortic Stenosis, and Abnormal Head CT

The patient requires immediate cardiac evaluation with cardiac catheterization followed by TEE for aortic valve assessment as the highest priority, with continuous cardiac monitoring throughout hospitalization. 1

Initial Risk Stratification

This patient presents with multiple high-risk features requiring urgent inpatient management:

• Unheralded syncope without prodrome (10 seconds duration)
• New left bundle branch block (LBBB)
• Moderate to severe aortic stenosis
• Abnormal head CT finding (meningioma vs. chronic intracranial hemorrhage)

Cardiac Evaluation Priority

1. Continuous cardiac monitoring - Essential throughout hospitalization due to risk of life-threatening arrhythmias

2. Cardiac catheterization - Should be performed first to:

   • Assess coronary anatomy
   • Evaluate hemodynamic significance of aortic stenosis
   • Rule out other cardiac causes of syncope

3. Transesophageal echocardiography (TEE) - Following catheterization to:

   • Provide detailed assessment of aortic valve anatomy
   • Guide decision-making for TAVR vs. surgical AVR
   • Evaluate for other structural cardiac abnormalities

Rationale for Cardiac Priority

The combination of syncope, LBBB, and moderate-severe aortic stenosis strongly suggests a cardiac etiology that requires immediate attention:

• Syncope in aortic stenosis is associated with poor outcomes and increased mortality (HR 2.11,95% CI: 1.39-3.21) 2
• LBBB in the setting of aortic stenosis may indicate conduction system disease requiring pacemaker implantation 3
• The ACC/AHA guidelines specifically identify aortic stenosis as a serious medical condition requiring inpatient evaluation and treatment 1

Neurological Evaluation (Secondary Priority)

After stabilizing the cardiac issues:

1. Neurology consultation for assessment of the abnormal head CT finding
2. MRI brain (not routine for syncope, but indicated here due to abnormal CT)
3. EEG only if seizure is suspected based on clinical presentation

The abnormal head CT finding is likely incidental rather than causative of syncope, as:

• Syncope is due to global cerebral hypoperfusion, not focal lesions 1
• MRI and CT have very low diagnostic yield (0.24% and 1% respectively) in syncope evaluation without focal neurological findings 1

Proposed Management Algorithm

1. Immediate phase (0-24 hours):

   • Continuous cardiac monitoring
   • Cardiac catheterization
   • TEE for aortic valve assessment

2. Early hospital phase (24-72 hours):

   • Neurology consultation for head CT findings
   • Decision on TAVR vs. surgical AVR
   • Consider permanent pacemaker placement if:
     • High-grade AV block is documented
     • Persistent LBBB with evidence of conduction disease

3. Pre-discharge phase:

   • Finalize aortic valve intervention plan
   • Implement pacemaker if indicated
   • Schedule follow-up for both cardiac and neurological issues

Common Pitfalls to Avoid

1. Delaying cardiac evaluation to focus on neurological findings - the cardiac issues pose the most immediate mortality risk
2. Attributing syncope primarily to the head CT finding - syncope due to intracranial lesions typically presents with focal neurological symptoms
3. Failing to recognize the significance of LBBB - new LBBB may indicate conduction system disease requiring pacemaker placement
4. Underestimating aortic stenosis - syncope in aortic stenosis indicates advanced disease with poor prognosis if untreated 2

Conclusion on Prioritization

The cardiac workup should take precedence, as aortic stenosis with syncope represents a high-risk condition with significant mortality. The neurological findings, while important, should be addressed after cardiac stabilization unless focal neurological symptoms develop.