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32
Syncope
William H. Maisel
Author
Patrick O'Gara
Editor
I. GENERAL PRINCIPLES
Cost of diagnosis and treatment approaches $750 million dollars per year.
II. PATHOPHYSIOLOGY
Systolic blood pressure less than 70 mm Hg or interruption of cerebral blood flow for 8 to 10 seconds
usually results in syncope.
Seizures cause loss of consciousness through global interruption of cerebral electrical activity without
necessarily impairing blood flow.
III. DIAGNOSIS
Differential diagnosis
Reflex mediated syncope and orthostatic intolerance are most common, whereas neurological,
cardiovascular, and psychogenic causes occur with decreasing frequency.
Up to 45% of patients will be labeled as having syncope of unknown cause despite a thorough
evaluation.
In absence of implantable defibrillator, syncope of cardiac etiology has 1-year mortality of 20% to
30% compared with 0% to 12% for patients with noncardiovascular causes of syncope and 6%
for those with syncope of unknown etiology.
Younger patients more frequently have syncope due to noncardiovascular cause or syncope of
unknown origin and overall have a more favorable prognosis.
Older patients more often have a cardiac etiology or syncope due to polypharmacy.
Algorithm for the approach to the patient with syncope (Fig. 32-1).
History and physical examination alone allow diagnosis of syncope cause in 45% of patients and
suggest a diagnosis in another 40%.
History
Search for situational or provocative factors, postural or exertional symptoms, and symptoms of
cardiac or neurologic origin.
Past medical history should focus on prior syncopal events, as well as prior cardiac, neurologic,
and psychiatric history.
Family history for familial cardiomyopathy, sudden cardiac death, or syncope should also be
sought.
Bradyarrhythmia
Sinus node disease
Obstruction to flow
Aortic stenosis
AV node disease
Mitral stenosis
Drug induced
Pacemaker malfunction
Tricuspid stenosis
Hypertrophic cardiomyopathy
Atrial myxoma
Tachyarrhythmia
Pulmonary stenosis
Ventricular arrhythmias
Supraventricular arrhythmias
Pulmonary embolism
Pulmonary hypertension
Cardiac tamponade
Aortic dissection
Pump failure (cardiomyopathy, MI)
Disorders of autonomic control
Autonomic insufficiency
Diabetes mellitus
Parkinson's disease
Primary
Reflex mediated
Neurocardiogenic (vasovagal/vasodepressor)
Carotid sinus hypersensitivity
Situational (cough, defecation, micturition, swallow)
Neuralgia (trigeminal, glossopharyngeal)
Neurologic
Psychiatric
Cerebrovascular disease (CVA, TIA)
Seizure
Hyperventilation
Major depression
Somatization
Migraine
Mnchhausen's
Narcolepsy
Substance abuse
Subclavian steal
Orthostatic hypotension
Metabolic
Volume depletion
Hypoadrenalism
Medication related
Hypoglycemia
Hypothyroidism
Hypoxia
Tongue biting, aching muscles, or disorientation following a syncopal episode suggests a seizure,
whereas sweating, nausea, vertigo, incontinence, injury, headache, family history of epilepsy, and
history of prior concussion are not predictive of seizures.
Figure 32-1. Algorithm for the approach to the patient with syncope.
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Physical examination
Should focus on identifying potential clues as to the etiology of the syncopal episode.
Orthostatic hypotension as etiology of syncope should be diagnosed only when the history and
examination are consistent and other potential etiologies of syncope have been excluded.
Murmurs, bruits, signs of heart failure, and so forth might suggest cardiovascular etiology.
Neurologic abnormalities such as diplopia, headache, or other focal signs may suggest a
neurologic etiology.
Half the patients who present with syncope have significant baseline ECG abnormalities.
The ECG alone is diagnostic of the cause of syncope in less than 10% of cases.
An abnormal ECG suggests the presence of underlying heart disease and warrants further
evaluation.
The ECG is the only way to diagnose some genetic disorders, including long QT syndrome and
Brugada syndrome.
Laboratory tests
Blood chemistries and hematologic assessments are appropriate as guided by the history and
physical examination.
Patient-activated loop recorders, event monitors, and implantable recorders can be used for
patients with infrequent but recurrent episodes.
TABLE 32-2 Indications for Cardiac Tests in Patients with Syncope
Test
Indication
Electrocardiogram
Echocardiogram
Electrophysiologic studies
Echocardiography
Part of the initial evaluation for patients with known or suspected cardiac disease.
Exercise testing
Rarely reveals the precise cause of syncope (less than 1% have an arrhythmia during
exercise testing).
Well established for detecting ventricular and supraventricular arrhythmias but less
sensitive for detecting bradyarrhythmias.
Patients with normal hearts and normal ECGs rarely require electrophysiology testing.
A positive EP study predicts an increased 3-year sudden death and total mortality rate
compared to patients with negative EP studies.
May be considered as an adjunct to other tests in the evaluation for arrhythmia, but it is not
routinely indicated
A number of syncope syndromes are related to abnormal control of autonomic function (see Table
32-1).
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More than 50% of patients with syncope of undetermined etiology may have neurally mediated
syncope.
Among patients with syncope of unknown origin, 25% to 50% will have positive tilt table
tests with passive tilt alone, and up to two thirds will have positive tests with the use of
isoproterenol.
False-positive (10% to 30%) and false-negative (30% to 35%) test results are common.
Performed by firm massage of the carotid artery for 5 to 10 seconds in an attempt to elicit a
baroreflex-mediated vagal response that can cause bradycardia and/or hypotension.
Should not be performed in patients with a carotid bruit, recent myocardial infarction,
recent stroke, or history of VT.
Neurologic evaluation
Patients with focal neurologic signs or symptoms should undergo further evaluation.
Additional neurologic testing is rarely indicated in the absence of specific clinical abnormalities or
suspicion.
Electroencephalography (EEG)
Yields diagnosis of seizure disorder in less than 2% of unselected patients with syncope
referred for EEG.
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Not recommended as part of the routine evaluation of patients with syncope but should be
considered when seizure is strongly suspected.
Unsuspected central nervous system abnormalities are found in less than 1% of patients
without neurologic abnormality on history or physical examination.
Should be reserved for patients with neurologic abnormality and those who have suffered
head trauma.
Psychiatric evaluation
Up to 25% of patients with syncope of unknown etiology have a Diagnostic and Statistical Manual
of Mental Disorders, fourth edition (DSM-IV) psychiatric diagnosis of panic disorder, generalized
anxiety disorder, or major depression.
Screening for psychiatric disorders is recommended for patients with recurrent syncope of unclear
etiology.
IV. TREATMENT
A history or suspicion of coronary artery disease, chronic heart failure (CHF), or ventricular
arrhythmia
Physical signs of significant valve disease, CHF, stroke, or focal neurological disorder
Frequent episodes
Intensive care unit (ICU) admission should be strongly considered in syncope patients with sustained
ventricular tachycardia (VT), symptomatic nonsustained VT, second- or third-degree heart block, pauses
greater than 3 seconds, symptomatic
P.179
bradycardia, severe aortic stenosis, severe CHF, evidence of acute ischemia, or ongoing hemodynamic
instability.
Specific treatment
Arrhythmia. Guidelines for implantation of permanent pacemakers and implantable cardioverterdefibrillators for patients with syncope are summarized in Table 32-3.
b-Adrenergic blockers, selective serotonin-reuptake inhibitors (e.g., fluoxetine), and aadrenergic agonists (midodrine) have demonstrated efficacy in randomized trials.
Other agents, including volume expanders (e.g., fludrocortisone) and disopyramide, appear
useful in some patients.
Patients with recurrent, medically refractory vasovagal syncope associated with marked
bradycardia may benefit from implantation of a permanent pacemaker.
Pacemaker
(IIb)
ICD
Psychiatric causes. Treatment of the underlying psychiatric disorder abolishes recurrent episodes
in most patients.
Special considerations
Patients suspected of having arrhythmic syncope should not drive, pending diagnosis and
treatment.
State laws vary with respect to the patient's and physician's responsibility to report individuals
with syncope to their respective department of motor vehicles. Physicians should become familiar
with their local requirements.
Selected Readings
Benditt DG, Ferguson DW, Grubb BP, et al. Tilt table testing for assessing syncope. JACC 1996;28:263275.
An excellent review of tilt table testing.
Gregoratos G, Cheitlin MD, Conill A, et al. ACC/AHA guidelines for implantation of cardiac pacemakers and
antiarrhythmia devices: Executive summary. Circulation 1998; 97:13251335. Guidelines for which syncope
patients should be treated with device therapy.
Kapoor WN. Evaluation and management of the patient with syncope. JAMA 1992; 268:25532560. Classic
article on syncope.
Linzer M, Yang EH, Estes III NAM, et al. Diagnosing syncope part 2: unexplained syncope. Ann Intern Med
1997;127:7686. A review of how to approach the challenge of the patient with unexplained syncope.
Linzer M, Yang EH, Estes III NAM, et al. Diagnosing syncope part 1: value of history, physical examination,
and electrocardiography. Ann Intern Med 1997;126:989996. An excellent review of the diagnostic
evaluation of patients with syncope.
Maisel WH, Stevenson WG. Syncopegetting to the heart of the matter. N Engl J Med 2002;347:931933.
A brief review of the approach to the syncope patient.
Soteriades ES, Evans JC, Larson MG, et al. Incidence and prognosis of syncope. N Engl J Med
2002;347:878885. A comprehensive study on the incidence and prognosis of syncope in the modern era.
Zipes DP, DiMarco JP, Gillette PC, et al. ACC/AHA guidelines for clinical intracardiac electrophysiological and
catheter ablation procedures. Circulation 1995;92:675691. Guidelines to help assist decision making
regarding which syncope patients require invasive evaluation.