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Learning Objectives
Recognize the vast etiologies of syncope Understand the importance of uncovering underlying organic heart disease Learn diagnostic and management strategies for neurally mediated syncope
You know, medicine is not an exact science, but we are learning all the time. Why, just fifty years ago, they thought a disease like your daughter's was caused by demonic possession or witchcraft. But nowadays we know that Isabelle is suffering from an imbalance of bodily humors, perhaps caused by a toad or a small dwarf living in her stomach. Theodoric, Barber of York
Case Presentation
38 year old male with hangover on flight for honeymoon to St. Lucia Stewardess asks for medical assistance as patient felt funny and then passed out What do you want to know?
Overview
Syncope is a symptom, not a disease In all forms, consists of a sudden decrease or brief cessation of cerebral blood flow Accounts for 3.5% of ER visits and 1-6% of all hospital admissions per year
Definition
Sudden and brief loss of consciousness associated with a loss of postural tone, from which recovery is spontaneous
Distinguishing Syncope
Dizziness, presyncope, Features to distinguish and vertigo syncope from seizure
No LOC or loss of postural tone
Drop attacks
Lead to falls without loss of consciousness Sometimes sign of vertebrobasilar TIA (15%)
Precipitants/Prodromal Symptoms
LOC precipitated by pain, exercise, micturition, defecation, or stressful event usually syncope Sweating, nausea = syncope Aura = Seizure Disorientation/ LOC > 5 minutes usually seizure rather than syncope
Important information
WITNESSES? Initial Assessment (especially HISTORY) will often lead to a clear diagnosis and help efficiently direct further workup and/ or treatment H and P leads to identification of cause in 45% of patients
Differential Diagnoses
Neurally Mediated Syncope (24%)
Vasovagal Situational Carotid Sinus
UNKNOWN (34%)
50-66% may be neurally mediated based on tilt-table studies
Soteriades, E., et al. Incidence and Prognosis of Syncope. NEJM 2002: 347:881
Risk Factors
Predictors of arrhythmic syncope or cardiac death at one year
CHF Ventricular tachyarrhythmias Abnormal ECG Age >45 years
Presence of 2 or more of these is associated with >10% incidence of syncope or cardiac death
Cardiac Differential
Cardiac Syncope: LOC often w/o prodrome
Indicates Outflow Obstruction AS, HOCM, PAH, Pulmonic Stenosis, PE
TIMBER!!!
Orthostatic Hypotension
Decline of >20mm Hg in SBP/ 10mm Hg in DBP from supine to standing Supine HTN common in these patients Elderly especially vulnerable
Baroreceptor sensitivity, Cerebral Blood Flow, renal sodium wasting, thirst response with aging
Neurologic Causes
Syncope rare manifestation of cerebrovascular disease Subclavian steal syndrome, Basilar Artery Migraine (syncope and HA) Vertebrobasilar insufficiency Drop Attacks
Diagnostic Evaluation
H and P! 45% of time can identify cause CBC, BMP ECG- Low yield but can be important clues to look for underlying heart disease CT Head, EEG: low yield Echocardiogram/ Stress Test: Helpful when presence of underlying cardiac disease cannot be determined clinically
History
Time of day Activities preceding (recurrent/at rest, exercise
associated, on standing)
Prodromes, associated symptoms Duration of LOC Injuries Medications, ingestions Cardiac History
Family History
Sudden unexplained death Deafness Arrhythmias Congenital heart disease Seizures Metabolic disorders Myocardial infarction at young age
Physical Exam
Pulse, blood pressure taken supine and standing after 3 minutes Murmurs, clicks of outflow tract obstruction Neurologic examination Carotid Massage (if no bruit)
Arrhythmia Testing
Telemetry Holter: 12-24 hours
symptoms w/ arrhythmia (5%) v. symptoms without arrhythmia (17%)
External Loop Recorders : can wear for weeks to months Implantable Loop Recorders: Monitor for 12-18 months
Provided diagnosis in 55% of pts with unexplained syncope compared to conventional methods
Management
Grubb BP.
Patient Instructions
Preventing Syncope or Vasovagal Spells
Avoid EtOH, lack of sleep, warm environment Maintain adequate hydration and food intake Avoid drugs that lead to hypotension Avoid activities that precipitate syncope
Bibliography
Kapoor, WN Syncope. NEJM 2000; 343: 1856-62 Freeman, R Neurogenic Orthostatic Hypotension NEJM 2008; 358: 615-624 Soteriades, et al. Incidence and Diagnosis of Syncope. NEJM 2002; 347:878-885 Grubb, B. Neurocardiogenic Syncope. NEJM 2005; 1004-1010
Thanks!