Lesson - 1

Syncope

Summary
1. Definition
2. Symptoms
3. Types
4. Causes
5. Differential diagnosis
6. Investigation
7. Treatment

Definition:

Syncope is defined as transient loss of consciousness due to diminished cerebral

perfusion(blood supply).

Symptoms:

1. Light headedness
2. Visual blurring
3. Dizziness
4. Sweating
5. Nausea

Types:

1. Neurally mediated (MOST COMMON)

a. Vasovagal syncope
b. Situational reflex syncope
2. Cardiac syncope (SECOND MOST COMMON)
a. Stokes-Adams syncope - due to atrioventricular block

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 3. Orthostatic hypotension

Causes:

Neurally mediated :

1. Vasovagal
2. Situational reflex
a. Cough
b. Sneeze
c. Airway instrumentation
d. Postmicturition syncope
e. Swallow syncope
f. Git instrumentation
g. Rectal examination
h. Defecation syncope
i. Carotid sensitivity
j. Carotid sinus massage

Cardiac syncope :

1. Arrhythmia
a. Sinus node infection
b. Sinus bradycardia
c. Heartblocks
d. Ventricular and supraventricular tachycardia
2. Cardiac structural disease
a. Aortic stenosis
b. Left ventricular dysfunction
c. Hypertrophic obstructive cardiomyopathy
d. Pericardial effusion and tamponade

Orthostatic hypertension :

1. Volume depletion

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 2. Iatrogenic (drud induced)
3. Primary autonomic failure due to idiopathic central and peripheral
neurodegenerative diseases
a. Parkinson’s disease
b. Multiple system atropy( Shy-Drager syndrome)
c. Secondary autonomic failure due to autonomic peripheral
neuropathies
d. Diabetes
e. Amyloidosis
f. Autonomic neuropathies

Differential diagnosis:

1. Anxiety
2. Hypoglycaemia
3. Seizures
4. Hysterical fainting

Investigation:

Diagnose:

● ECG
● echocardiography
● Holter ECG
● electrophysiological studies

Confirmation - Upright tilt test

For neurological cause diagnosis

● EEG
● CT
● MRI

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Treatment:

Neurally mediated syncope:

1. Plasma volume expansion (fluids and salts)

2. Avoidance of precipitating factors
3. Reassurance

Orthostatic hypotension:

1. Staged movement (supine to upright position)

2. Raising the head of the bed
3. Increased dietary fluid and salts
4. Use of fludrocortisone acetate and vasoconstricting agents (midodrine,
pseudoephedrine)

Cardiac syncope:

1. Anti-arrhythmia drugs
2. Radiofrequency ablation
3. Cardiac pacing (AV block and sinus node disease)
4. Cardioverter defibrillator implantation (atrial and ventricular arrhythmia)

Action during syncope:

● Supine position, head tilted to side - maximise cerebral blood flow,

avoid aspiration
● Peripheral stimulation (water sprinkle to face)
● Not allowed to rise till weakness persists

Patient instruction:

● Avoid situation that causes syncope

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 ● During premonitory symptoms, assume recumbent position
● In recurrent syncope, avoid ladders, swimming alone, driving, operating
machines

Stokes-Adams syncope:

Stokes-Adams syndrome is a condition where you suddenly feel faint and can pass
out. It’s caused by a change in your heart rate.

This affects how much blood flows to your brain because your heart either beats too
slowly or too quickly. That’s what causes you to faint.

It’s also known as Adams-Stokes disease or Stokes Adams attacks.

Holter ECG:

A Holter monitor (often simply Holter) is a type of ambulatory

electrocardiography device, a portable device for cardiac monitoring (the
monitoring of the electrical activity of the cardiovascular system) for at least
24 to 72 hours (often for two weeks at a time).