Chap 4

Jiaqi Zhao

Department of Cardiology, Affiliated Hospital of Ji ning Medical College, Ji ning

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Definition Epidemiology Why it’s important Possible causes Distribution of causes in community Clues to diagnosis Approach


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Abrupt and transient loss of consciousness Absence of postural tone Spontaneous rapid and full recovery


Sorteriades ES, et al. NEJM. 2002

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Actual rates likely higher 30% of young adults report prior episode of syncope 6% annual incidence in elderly

Why it’s Important

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1. 2. 3. 4.

Olshansky B. Up to Date, updated April 2005 Kapoor W. JAMA 1992 Nyman JA, et al. Pacing Clin Electr 1999 Linzer M, et al. J Clin Epid 1991

Alarming to patient, family and clinicians Injuries occur in ~35% of patients1 Accounts for 1% of hospital admissions and 3% of ER visits2 Annual evaluation and treatment cost of $800M in 19993 Recurrent episodes = poor QOL4

Broad Causes of Syncope
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Reflex mediated Orthostatic hypotension Cardiac dysrhythmia Cardiac Obstruction Neurologic Metabolic Unexplained

Reflex Mediated
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Neurocardiogenic (vasovagal) Carotid sinus hypersenstivity Micturition Cough Defecation Deglutition Postprandial Gelastic1
1. Braga SS et al. Lancet 2005

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Medication related Fluid depletion Illness/bedrest Dysautonomias

Bradbury Eggleston Syndrome (pure autonomic failure) Shy Drager Syndrome (multiple system atrophy) Parkinsonism with autonomic failure

Cardiac Dysrhythmia

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Sinus node disease AV and infranodal conduction system disease SVT with accessory AV pathway VT with structural heart disease VT with no structural heart disease

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Cardiac Obstruction
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Aortic stenosis Atrial myxoma Hypertrophic cardiomyopathy with obstruction Severe pulmonary hypertension Pulmonary embolism Cardiac tamponade

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Hypoglycemia Hypoxia Hyperventilation

Framingham Heart Study
40 35 30 25 20 15 10 5 0
e/ TI A tic al n tio ic a ar di ac ow n re so va g nk n St ro k Se O rt ho C M ed Va U O th iz u st a er

Soteriades ES et al. NEJM. 2002.


Sorteriades ES, et al. NEJM. 2002

Helpful Clues in History
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Age Context Pattern Prodrome Observations of witnesses Chronic Illnesses/known cardiac disease Medications

History, Physical and ECG

Clear cut reflex mediated or orthostatic

Specific mechanism suspected

Not a clue !!!


Dx specific testing

Exclude fatal causes

Strickberger SA et al. JACC 2006

Potentially Fatal Causes
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Silent ischemia/unrecognized CAD Structural heart disease
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Impaired systolic function (low EF) Hypertrophic cardiomyopathy Arrhythmogenic right ventricular dysplasia (ARVD) Long QT syndrome Brugada syndrome Catecholaminergic polymorphic ventricular tachycardia Presence of an accessory pathway

Primary electrical disease
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Syncope in Known CAD
Echo EF <35% EF >35%


Cath +/- revascularization

EP Study unremarkabl e Observe/ILR Unstable SVT/AP Sinus node or conduction PPM dz Ablate/PPM with AT Rx

monomorphic VT ICD/ablate

Syncope in HCM
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Annual risk of SCD is 0.6 to 1% EP studies generally not useful Risk factors for sudden death
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Syncope !!! Family history of SCD Frequent NSVT Wall thickness > 30 mm Genotyping not ready for prime time

ICDs are effective

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~20% of SCD in pts < 35 may be due to ARVD 30-50% are familial, others sporadic Present with PVCs, syncope, sustained VT with LBBB morphology Utility of EP testing not established With ICD rx, the annual rate of appropriate shocks is 15-20%

Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy


Kies P et al. J Cardiovasc Electrophysiol; 17: 586-593. 2006

Long QT Syndrome

Brugada Syndrome

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