2/26/2013

Syncope
Keeping Passing Out from Passing On
Carmine D’Amico, D.O. Eric Milie, D.O.

Syncope

Overview
• • • • • • •

Learning objectives Introduction Etiology Diagnosis Treatment Prognosis Summary

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2/26/2013

Syncope

Learning objectives
1. Define syncope. 2. Discuss the relative incidences of the various

causes of syncope. 3. State the minimum diagnostic workup for every patient with syncope. 4. Identify the most likely cause of syncope based on clinical presentation. 5. Name the diagnostic test of choice for a patient suspected of having neurocardiogenic syncope.

Syncope

Introduction
Definition:
Temporary loss of consciousness and postural tone due to transient cerebral hypoperfusion, followed by spontaneous recovery.

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) Syncope is only one of many conditions that cause transient loss of consciousness (TLOC)… Syncope Transient Loss of Consciousness Trauma-induced Not Trauma-induced Not True TLOC Concussion • Syncope • Seizures • Intoxications • Metabolic disorders TLOC mimics.g. without true loss of consciousness e.. psychogenic “pseudosyncope” – ‘drop attacks’ – cataplexy – 3 .2/26/2013 Syncope Introduction (cont.

) Incidence • Children and adolescents • 15 to 20% will experience syncope before adulthood • Adults • 30 to 50% • Elderly • 2 to 6% annual incidence 4 .g. alcohol) • Seizures • Sleep disorders • Somatization disorder • • psychogenic pseudo-syncope Trauma/concussion • Hypoglycemia • Hyperventilation • Syncope Introduction (cont.2/26/2013 Syncope Syncope Mimics: Real or seemingly real TLOC not due to cerebral hypoperfusion: Acute Intoxication (e.

MD. 5 . Emond. Camargo. Sun. MD..) Impact • 3% of emergency room visits • 1% of hospital admissions • Estimated annual cost (eval.000 * *Benjamin C. Jr.400. MPP.95:668-671 Syncope Etiology The specific cause of syncope can be identified in approximately 75% of patients.2/26/2013 Syncope Introduction (cont. DrPH “Direct medical costs of syncope-related hospitalizations in the USA Am J Cardiol 2005. and tx): $2.000. and Carlos A. MS. Jennifer A.

2/26/2013 Syncope Etiology (cont.) • • • • • • • • Neurological / Cerebrovascular (<10%) Seizure Migraine (basilar artery) TIA (basilar artery) Vertebrobasilar insufficiency Arnold-Chiari malformation Concussion Cerebral syncope 6 .) • Cardiovascular • Cardiac • Vascular • • • • Neurological / Cerebrovascular Metabolic Psychiatric Unexplained Syncope Etiology (cont.

) • • • Rare cause of syncope Orthostatic cerebral vasoconstriction in the absence of systemic hypotension “Cerebrovascular dysautoregulation syndrome” Syncope Etiology (cont.2/26/2013 Syncope Etiology (cont.) • Metabolic (<5%) • • • • Hypoglycemia Hypoxia Hyperventilation (hypocapnea) Drug / alcohol intoxication 7 .) • • Neurological / Cerebrovascular (cont.) Cerebral syncope (cont.

) • Psychiatric (estimated that up to 25% of unexplained syncopal episodes may be psychogenic) • • • Hysterical faint Panic disorder Anxiety disorder Syncope Etiology (cont.) • Cardiovascular (50 to 60%) • Cardiac • Electrical • Mechanical • Vascular • Reflex-mediated • Anatomical • Orthostatic 8 .2/26/2013 Syncope Etiology (cont.

) In order to fully understand the cardiovascular causes of syncope… Syncope “Plumbing 101” • CO = SV x HR CO = cardiac output SV = stroke volume HR = heart rate • SV is determined by: • • • Contractility Preload Afterload 9 .2/26/2013 Syncope Etiology (cont.

2/26/2013 Syncope Etiology (cont.) • Cardiac (cont. heart rates between 30 and 180 bpm do not result in significant reduction in cerebral blood flow (esp. in normal individuals.) • Cardiac • Electrical • Bradyarrhythmia • Sinus node dysfunction • AV nodal block • Artificial pacemaker malfunction • Tachyarrhythmia • Supraventricular • Ventricular Syncope Etiology (cont. in the supine position). 10 .) • Electrical (cont.) • In general.

) • Cardiac (cont.2/26/2013 Syncope Etiology (cont.) • Electrical (cont.) • Cardiac (cont.) • Mechanical • • • • • • • Aortic stenosis Hypertrophic cardiomyopathy Mitral stenosis Myxoma / ball-valve thrombus Prosthetic valve malfunction Pulmonic stenosis Tetralogy of Fallot 11 .) • Circumstances in which extremes of heart rate are poorly tolerated: • • • • Severe LV systolic dysfunction Significant LV diastolic dysfunction Significant mitral stenosis (esp. AF with RVR) Significant coronary artery disease Syncope Etiology (cont.

2/26/2013 Syncope Etiology (cont.) • Vascular (most common) • Reflex-mediated • • Trigger (afferent limb) Response (efferent limb) • Anatomical • Orthostatic 12 .) • Pulmonary embolism • Severe pulmonary hypertension • Myocardial ischemia or infarction • Presenting symptom in 7% of elderly with MI • Coronary spasm • Pericardial tamponade • Aortic dissection Syncope Etiology (cont.) • Cardiac (cont.) • Mechanical (cont.

neurally mediated.: vasodepressor.) • Vascular (cont. common faint) • Carotid sinus hypersensitivity • Situational • Glossopharyngeal neuralgia 13 .k.varies with each specific type of reflex-mediated syncope • Response (efferent) limb.) • Neurocardiogenic (a.) • Reflex-mediated • Trigger. vasovagal.a.essentially the same for all types of reflex-mediated syncope: • • Increased vagal tone Withdrawal of sympathetic tone Syncope Etiology (cont.2/26/2013 Syncope Etiology (cont.) • Reflex-mediated (cont.) • Vascular (cont.

2/26/2013 Syncope Etiology (cont.) • Vascular (cont.) • Neurocardiogenic syncope • Potential triggers: • • • • • Prolonged standing Warm environment Pain Sight of blood Emotional distress 14 .) • Reflex-mediated (cont.

) • Carotid sinus hypersensitivity • Potential triggers: • • • • Anything that stimulates the carotid sinus baroreceptors Cardioinhibitory Vasodepressor Mixed • 3 types of abnormal responses: 15 .) • Vascular (cont.2/26/2013 Syncope Etiology (cont.) • Reflex-mediated (cont.

) • Carotid sinus hypersensitivity (cont.) • Cardioinhibitory • > 3 second pause • Vasodepressor • > 50 mmHg fall in systolic BP in the absence of bradycardia • Mixed • > 3 second pause and > 50 mmHg fall in systolic BP 16 .2/26/2013 Syncope Etiology (cont.) • Vascular (cont.

) • Vascular (cont.) • Reflex-mediated (cont. tonsillar fossa.) • Reflex-mediated (cont.) • Situational syncope • • • • • Cough (tussive) Micturition Defecation Valsalva Deglutition Syncope Etiology (cont.) • Glossopharyngeal neuralgia • Syncope preceded by pain in oropharynx.) • Vascular (cont. or tongue • Trigger: activation of afferent impulses in CN IX 17 .2/26/2013 Syncope Etiology (cont.

why isn’t this phenomenon called vertebral steal syndrome? 18 . use of the ipsilateral arm may result in reversal of blood flow from the vertebral artery to the subclavian artery (blood is stolen from the vertebral artery).) • Anatomical • Subclavian steal syndrome • Due to significant stenosis in the subclavian artery proximal to the takeoff of the vertebral artery.2/26/2013 Syncope Etiology (cont.) • Vascular (cont. • So.

drugs) • Neurogenic • Primary autonomic failure • Secondary autonomic failure • Postprandial 19 .) • Vascular (cont.) • Orthostatic hypotension • Definition: > 20 mmHg drop in systolic BP or > 10 mmHg drop in diastolic BP within 3 minutes of standing • Responsible for up to 30% of syncopal episodes in the elderly Syncope Etiology (cont.) • Multiple causes: • Volume depletion (incl. drugs) • Vasodilatation (incl.) • Orthostatic hypotension (cont.) • Vascular (cont.2/26/2013 Syncope Etiology (cont.

2/26/2013 Syncope Diagnosis • History and physical examination are usually the most important clues leading to the diagnosis. • A 12-lead electrocardiogram (EKG) should be performed on every patient who presents with syncope. • Further diagnostic testing should be tailored to the suspected etiology. Syncope Diagnostic Evaluation of Syncope 20 .

) A 12-lead EKG is performed. Do you notice anything unusual? 21 . Lead II from this EKG is shown below. Syncope Diagnosis (cont.2/26/2013 Syncope Diagnosis (cont.) A 14-year-old girl experiences a “blackout” when her boyfriend breaks up with her. including orthostatic blood pressures. is normal. Physical examination.

2/26/2013 Syncope Diagnosis (cont. ambulatory cardiac monitoring with an external loop recorder. and electrophysiological testing. he experienced another syncopal episode… 22 .) A 55-year-old man with 11 previous episodes of syncope over 7 years remained undiagnosed following tilt testing.) 7 months later. Syncope Diagnosis (cont.

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) Recommendations for driving • Consider: • • • • Potential for recurrence Presence and duration of warning symptoms Does syncope only occur while standing? Frequency and capacity in which the patient drives • Applicable state laws 24 .2/26/2013 Syncope Treatment Therapy must be tailored to the specific cause: • • • • Avoidance Correction Interrupt reflex limbs (modulate the ANS) Pacemaker and / or ICD implantation Syncope Treatment (cont.

Therapy should be directed at the specific cause whenever possible. unexplained syncope in individuals with structural heart disease is associated with a 2-year mortality of 40%. • • • 25 . Further diagnostic testing should be tailored to the suspected etiology.2/26/2013 Syncope Prognosis Underlying etiology determines prognosis • Cardiac syncope carries the worst prognosis: • Recurrent. Syncope Summary • History and physical examination are usually the most important clues leading to the diagnosis. Always perform an EKG.