Anndy Prastya

Department of Emergency Nursing

Stikes Majapahit Mojokerto

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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

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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 ED visits and 1-6% of all
hospital
admissions per year

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Definition
Sudden and brief loss of consciousness associated
with a loss of postural tone, from which recovery is
spontaneous

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Distinguishing Syncope
Dizziness, Features to
presyncope, and distinguish syncope
vertigo from seizure
 No LOC or loss of  Prodromal/
postural tone Premonitory
“Drop attacks” symptoms
 Lead to falls without loss  Precipitating event
of consciousness
 Events that follow it
 Sometimes sign of
vertebrobasilar TIA (15%)

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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

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Important information
WITNESSES?
Initial Assessment (especially HISTORY) will
often lead to a clear diagnosis and help efficiently
direct further workup and/ or treatment
History and physical findings lead to identification
of cause in 45% of patients

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Differential Diagnoses
Neurally Mediated Neurologic Dz (10%)
Syncope (24%)
Cardiac Syncope
 Vasovagal
 Organic Heart Disease
(4%)
 Situational

 Arrhythmias (14%)
 Carotid Sinus

Orthostatic UNKNOWN (34%)

Hypotension (10%)  50-66% may be neurally
mediated based on tilt-
Psychiatric Disorders table studies
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Soteriades, E., et al. Incidence and Prognosis of Syncope. NEJM 2002: 347:881

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Structural Heart Disease
Presence of a structural heart disease (CAD, CHF,
Valvular Heart Disease, CHD) is the most
important risk factor for predicting the risk of
death
Have ↑ risk of death at one year
Most arrhythmias are found in these patients

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Soteriades, E. et al. Incidence and Prognosis of Syncope. NEJM 2002; 347:883
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

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Cardiac Differential
Cardiac Syncope: LOC often w/o prodrome
 Indicates Outflow Obstruction
 AS, HOCM, PAH, Pulmonic Stenosis, PE
 MI, UA, Coronary Artery Spasm, Aortic
Dissection
 Arrhythmias
 Prolonged QT (either Congenital or Drug Induced)
 AV Block, Sinus Node Dysfunction
 Ventricular tachycardia
 Arrhythmogenic right ventricular dysplasia
 Supraventricular tachycardia (Wolff-Parkinson-White)
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Neurally Mediated Syncope
Most Common Causes
Vasovagal, Situational, and Carotid Sinus Syncope
Results from sudden reflex mediated hypotension/
and or bradycardia
Triggered by various stretch/ mechanoreceptors
(carotid sinus, bladder, esophagus, respiratory
tract

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Carotid Sinus Syncope and Autonomic Dysfunction

Freeman, M. Neurogenic Orthostatic Hypotension. NEJM 2008; 358: 616

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Neurally Mediated Syncope Pathophysiology
Peripheral Venous Pooling ↑ causes sudden ↓ in
peripheral venous return
Leads to cardiac “hypercontractile” state which
activates stretch receptors
Neural traffic ↑ to brain mimics severe
hypertension and provokes paradoxical bradycardia
and ↓ in PVR

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Orthostatic Hypotension
Decline of  20mm Hg in SBP or HR  2o/mnt
within
2 minute, from supine to standing
Elderly especially vulnerable
 ↓ Baroreceptor sensitivity, ↓ Cerebral Blood Flow, ↑
renal
sodium wasting, ↓thirst response with aging
Peripheral sympathetic tone impairment
 Diabetic neuropathy, antihypertensive medication

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Neurologic Causes
Syncope rare manifestation of cerebrovascular
disease
Subclavian steal syndrome,
Basilar Artery Migraine (syncope and HA)
Vertebrobasilar insufficiency “Drop Attacks”

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Diagnostic Evaluation
History and Physical findings! – 45% of time can
identify cause
CBC, nt-proBMP
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 19
History
Time of day
Activities preceding (recurrent/at rest,
exercise associated, on standing)
Prodromes, associated symptoms
Duration of LOC
Injuries
Medications, ingestions
Cardiac History

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Family History
Sudden unexplained death
Deafness
Arrhythmias
Congenital heart disease
Seizures
Metabolic disorders
Myocardial infarction at young
age

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Physical Exam
Pulse, blood pressure – taken supine and
standing
after 3 minutes
Murmurs, clicks of out flow tract obstruction
Neurologic examination
Carotid Massage (if no bruit)

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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
EP Studies: Helpful with structural 23
Tilt Table Test
Used to
evaluate
autonomic
nervous system
Evaluates
predisposition to
neurally
mediated
syncope
Specificity of
negative test 24
Indications for Tilt Table Testing
Unexplained recurrent syncope

Single episode associated with injury or in settings

that pose a high risk of injury
If organic heart disease is present, than after
cardiac causes have been excluded
Evaluation of recurrent syncope in setting
of autonomic failure
Assessment of recurrent, unexplained falls

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Indications for Hospital Admission
History of CAD, CHF, Ventricular
Arrhthmia
Accompanying Chest Pain
Abnormal ECG
Moderate to severe orthostatic hypotension
Age > 70 yrs
Resulting Trauma

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Management of Neurally Mediated Syncope

Grubb BP. NEJM. 2005. 352(10): 1004-1010

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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

Preventing LOC or Injury

 Assume supine position upon onset of prodrome
 Avoid driving or other activities that could lead to

injury

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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

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Thanks!

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