(Syncope)

(postural tone)

1.Reflex-mediated vasomotor instability

Vasovagal
Situational: micturition, cough, swallowing, defecation
Carotid sinus syncope
Neuralgia
High altitude
Psychiatric

2.Orthostatic hypotension
Drugs
Primary disorders of autonomic failures
Secondary neurogenic causes

3.Neurological
Migraine
TIA
Seizure

4.Decreased cardiac output

(1)Obstruction to Flow
Obstruction to LV outflow: aortic stenosis,
HOCM, MS, myxoma
Obstruction to RV outflow: pulmonary
stenosis, pulmonary HTN, Pulmonary
embolism, myxoma
(2)Arrhythmia
Bradyarrhythmias
Tachyarrhythmias
(3)Other hear disease
Pumping failure: MI, CAD
Aortic dissection
Cardiac tamponade

vasovagal
syncope.

SSituational
Y Vasovagal ( Y V)
N Neurological
C Cardiac AMIarrhythmiacardiac tamponade
O Orthostatic hypotension vasodilatordiuretic
P Psychologicalemotion stress
E Everything else sedativecocaine elicit drugs

SYNCOPE

HISTORY, PE and EKG

DIAGNOSTIC NEGATIVE

SUGGESTIVE
Example
Vasovagal syncope
Situational syncope
Orthostatic hypotension No heart disease Heart disease or
Drug-induced abnormal EKG
Arrhythmia by EKG

Holter

CNS disease: Reduced cardiac output:

RVOT obstruction Carotid sinus syncope Diagnostic
TIA, subclavian steal, LVOT obstruction
migraine, seizure, focal MI
neurologic finding Cardiac tamponade

Carotid massage Treat Nondiagnostic

EEG Echocardiogram
Head CT or MRI Cardiac catheterization
Cerebral flow study CPK/MB for MI
Angiography Lung scan Multiple episode One episode
Pulmonary angiography

Tilting test Vasovagal

Psychiatric evaluation Psychiatric
Loop monitor

Loop monitor Multiple episode One episode

Nondiagnostic EPS

Treat Positive Negative

Tilt table testing Multiple episode

Psychiatric evaluation

Reference
Ch37. Hypotension and syncope. Braunwalds HEART DISEASE 8th edition SAUNDERS 2008