the last one topic syncope

7/31/2019 The Last One Topic Syncope

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June 28 , 2012

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TOPIC REVIEW

SYNCOPE


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Syncope (Greek -- to interrupt)

Sudden transient loss of consciousness with associated loss ofpostural tone.

Recovery is spontaneous without neurologic deficitand withoutrequiring electrical or chemical cardioversion.

If SBP < 70 mmHg or MAP < 40 mmHg

loss of consciousness

SYNCOPE


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THE SIGNIFICANCE OF SYNCOPE

The only difference between

syncope and sudden death

is that in one you wake up.1

1 Engel GL. Psychologic stress, vasodepressor syncope, and sudden death. Ann Intern Med1978; 89: 403-412.


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1 Day SC, et al. Am J of Med1982;73:15-23.

2 Kapoor W. Medicine1990;69:160-175.3 Silverstein M, Sager D, Mulley A. JAMA. 1982;248:1185-1189.

4 Martin G, Adams S, Martin H. Ann Emerg Med. 1984;13:499-504.

Some causes of syncope are potentially fatal Cardiac causes of syncope have the highest mortality rates

0%

5%

10%

15%

20%

25%

SyncopeMortality

Overall Due to Cardiac Causes

THE SIGNIFICANCE OF SYNCOPE


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SYNCOPE

A SYMPTOM, NOT A DIAGNOSIS

Underlying mechanism istransient global cerebralhypoperfusion.

Brignole M, et al. Europace, 2004;6:467-537.


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Stroke volume Heart rate

Cardiac outputSystemic vascularresistance

Arterial pressure

Cerebral blood flow

Metabolic regulationChemical regulation

Cerebrovascularresistance

autoregulation

SYNCOPE PATHOPHYSIOLOGY


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0 5 10 15 20 25

0.0

0.2

0.4

0.6

0.8

1.0

Follow-up (yr)

Probability

ofSurvival

No syncope

Vasovagal and

other causesUnknown cause

Neurologic cause

Cardiac cause

Figure 2. Overall Survival of Participants with Syncope, According to Cause, and Participants without Syncope.

P


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In young (65 years)

Cardiac (Arrhythmic, Mechanical)

Orthostatic Neurally mediated

Arthur W,et al. Postgrad Med J2001.

COMMON CAUSES OF SYNCOPE


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DIAGNOSTIC ASSESSMENT: YIELDS

(N=3411 TO 4332)

References Available

Yield (%)

Initial Evaluation

History, Physical Exam, ECG, Cardiac Massage38-40

Other Tests/Procedures

Head-Up Tilt 27

External Cardiac Monitoring 5-13

Insertable Loop Recorder (ILR) 43-883-5

EP Study


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Is it a syncopal episode or other type of event?

Has the etiology been determined?

Is there evidence suggestive of a high risk of

cardiovascular events or death* ?

KEY QUESTIONS IN INITIAL EVALUATION


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Is it a syncopal episode or

other type of event? Has the etiology been determined?





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DISTINCTION OF SYNCOPE FROM SEIZURE Favour seizure

Prolonged tonic clonic

activity

Stereotype

Aura or

short neurological warning

Slow recovery

Favour Syncope

Short tonic clonic

movement < 15 sec

after LOC

Prodrome

Flaccid

Pale

Quick recovery


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SYNCOPE: ETIOLOGY

OrthostaticCardiac

Arrhythmia

StructuralCardio-

Pulmonary

*

1 Vasovagal Carotid

Sinus SituationalCoughPost-

micturition

2 Drug

Induced ANS

FailurePrimarySecondary

3 BradySick sinusAV block

TachyVTSVT

Long QTSyndrome

4 Aortic

Stenosis HOCM PulmonaryHypertension

5 Psychogenic Metabolic

e.g. hyper-ventilation

Neurological

Non-Cardio-

vascular

Neurally-Mediated

Unknown Cause = 34%

24% 11% 14% 4% 12%

DG Benditt, UM Cardiac Arrhythmia Center


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Is there evidence suggestive of a high risk

of cardiovascular events or death* ?



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EVALUATION : HISTORY


20/32ESC Guidelines for the diagnosis and managementof syncope (version2009)

Circumstances just prior to attack:

Position (supine, sitting, or standing)

Activity (rest, change in posture, during or after

exercise etc.)

Predisposing factors (e.g., crowded or warm places,

prolonged standing, post-prandial period) and of

precipitating events


21/32ESC Guidelines for the diagnosis and managementof syncope (version 2009)

During attack , end of attack, eyewitness :

Number of episode Sudden onset

Prodrome

Duration Way of falling (slumping or kneeling over)

Skin color (pallor, cyanosis, flushing)

Breathing pattern (snoring)

Movements and their duration


22/32ESC Guidelines for the diagnosis and managementof syncope (version 2009)

Background:

Family history of sudden death, congenitalarrhythmogenic heart disease or fainting

Previous cardiac disease

Neurological history (Parkinsonism, epilepsy,

narcolepsy)

Metabolic disorders (diabetes, etc.)

Medication : Anti HT drug , anti arrhythmic drugs


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DRUG-INDUCED QT PROLONGATION

Antiarrhythmics Class IA ...Quinidine,

Procainamide,

Disopyramide

Class IIISotalol, Ibutilide,

Dofetilide, Amiodarone,

Psychoactive Agents

Phenothiazines,Amitriptyline, Imipramine,

Ziprasidone

Antibiotics Erythromycin, Pentamidine,

Fluconazole, Ciprofloxacin

and its relatives

Nonsedating antihistamines Terfenadine*, Astemizole

Others

Cisapride*, Droperidol,Haloperidol

*Removed from U.S. MarketBrignole M, et al. Europace, 2004;6:467-537.


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EVALUATION :PHYSICAL EXAMINATION

A number of findings on physical examination can aid in the identification of some of

the common causes of syncope *

Linzer M, Yang EH, Estes NA 3rd, et al. Diagnosing syncope. Part 1: Value of history, physical

examination, and electrocardiography. Clinical Efficacy Assessment Project of the AmericanCollege of Physicians. Ann Intern Med 1997; 126:989
http://www.uptodate.com/contents/evaluation-of-syncope-in-adults/abstract/8http://www.uptodate.com/contents/evaluation-of-syncope-in-adults/abstract/8http://www.uptodate.com/contents/evaluation-of-syncope-in-adults/abstract/8http://www.uptodate.com/contents/evaluation-of-syncope-in-adults/abstract/8http://www.uptodate.com/contents/evaluation-of-syncope-in-adults/abstract/8http://www.uptodate.com/contents/evaluation-of-syncope-in-adults/abstract/8


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Abnormal vital signs

: BP in supine , sitting , erect position

Disturbances in heart rhythm or breathing

: HR ,rhythm ,ventilation

Cardiac auscultatory findings

: AS , PS or atrial myxoma , PHT

Physiologic maneuvers : valsalva maneuver

Abnormal neurologic findings

Gastrointestinal bleeding


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SYNCOPE: ETIOLOGY

OrthostaticCardiac

Arrhythmia

StructuralCardio-

Pulmonary

*

1 Vasovagal Carotid

Sinus SituationalCoughPost-

micturition

2 Drug

Induced ANS

FailurePrimarySecondary

3 BradySick sinusAV block

TachyVTSVT

Long QTSyndrome

4 Aortic

Stenosis HOCM PulmonaryHypertension

5 Psychogenic Metabolic

e.g. hyper-ventilation

Neurological

Non-Cardio-

vascular

Neurally-Mediated

Unknown Cause = 34%

24% 11% 14% 4% 12%

DG Benditt, UM Cardiac Arrhythmia Center


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THANK YOU FOR YOUR ATTENTION

the last one topic syncope

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