SYNCOPE

SYNCOPE
How BIG is the impact? Cardiac related

Framingham Heart Study

ED Visit
1-3% Related to Syncope

Impact?

COST: 34, 825, 129 USD /100.000 inhabitant/year

Brignole M. Syncope: an evidence-based approach. Place of publication not identified: Springer; 2014.
Benditt D. Syncope in adults: Epidemiology, pathogenesis, and etiologies [Internet]. Syncope in adults: Epidemiology, pathogenesis,
and etiologies. 2017 [cited 2017Aug25]. Available from: https://www.uptodate.com/contents/syncope-in-adults-epidemiology-
 SYNCOPE
How probable is the mortality?
SYNCOPE is....

A sign
A Premonition
5 year survival rate:

50 percent
30% of death in the first year

Benditt D. Syncope in adults: Epidemiology, pathogenesis, and etiologies [Internet]. Syncope in adults:
Epidemiology, pathogenesis, and etiologies. 2017 [cited 2017Aug25]. Available from:
https://www.uptodate.com/contents/syncope-in-adults-epidemiology-pathogenesis-and-etiologies?
 SYNCOPE
Definition

Syncope Clinical symptom Loss of consciousness

Characteristic Effect

Transient Self Limited

Loss of posture/fall
Recovery

Spontaneous, complete, and prompt

Transient period of global cerebral hypoperfusion

What causes the transient global cerebral hypoperfusion?

Camm AJ, Luscher Thomas Felix, Serruys PW. The ESC textbook of cardiovascular medicine. Oxford: Oxford
University Press; 2009.
 SYNCOPE
How brain is perfused? What causes the LOC?

12-15% of resting cardiac output

Cerebral blood flow: 50-60 ml/100g tissue/minute

Decrease in SBP to 60 mmHg

6-8 second cessation of flow

Loss of Consciousness

Keyword: Transient Global Cerebral Hypoperfusion

20% drop in cerebral oxygen delivery

Camm AJ, Luscher Thomas Felix, Serruys PW. The ESC textbook of cardiovascular medicine. Oxford: Oxford
University Press; 2009.
 SYNCOPE
Whats the cause?

Syncope Cathegorized into 4 causes (True syncope)

Reflex Syncope Orthostatic syncope Cardiac Arrhythmias Structural Cardiopulmonary disease

Benditt D. Syncope in adults:

Epidemiology, pathogenesis,
and etiologies [Internet]. 2017
[cited 2017Aug25]. Available
from:
https://www.uptodate.com/cont
ents/syncope-in-adults-
epidemiology-pathogenesis-
and-etiologies?
source=see_link
 SYNCOPE
Reflex Syncope - Pathophysiology

Cardioinhibitory response
Baroreceptor reflex
Type of response Vasodepressor response Autonomic dysfunction

Mixed response Carotid sinus reflex

Benditt D. Reflex syncope in adults: Clinical presentation and diagnostic evaluation [Internet]. 2017 [cited 2017Aug26]. Available from:
https://www.uptodate.com/contents/reflex-syncope-in-adults-clinical-presentation-and-diagnostic-evaluation?source=see_linkionName=TYPES OF REFLEX
 SYNCOPE
Reflex Syncope Type
Vasovagal Syncope Situational syncope
1. Common faint 1. Speficic scenarios
2. Self-limited hypotension 2. Ex: Post-micturition, post-tussive
3. Without apparent trigger neural reflex
cardiovascular or neurologic 3. Trigger neural reflex
disease

Carotid sinus syncope
1. Precipitating factors:
accidental mechanical
manipulation
2. Ex: pressure from shaving,
tight collars
Benditt D. Reflex syncope in adults: Clinical presentation and diagnostic evaluation
[Internet]. 2017 [cited 2017Aug26]. Available from:
https://www.uptodate.com/contents/reflex-syncope-in-adults-clinical-presentation-and-
diagnostic-evaluation?source=see_linkionName=TYPES OF REFLEX
SYNCOPE&anchor=H2305727192#H2305727192
Olhansky B. Carotid sinus hypersensitivity [Internet]. Carotid sinus hypersensitivity.
2015 [cited 2017Aug26]. Available from: https://www.uptodate.com/contents/carotid-
sinus-hypersensitivity?source=see_link
 SYNCOPE
Reflex Syncope Clinical clue

Prodromal symptoms
Vasovagal syncope PREMONITION Lightheadedness
A feeling of being warm or cold
Sweating
Short in duration : one to two minutes Palpitations
Nausea or non-specific abdominal
discomfort
Apparent post-episode fatigue Visual "blurring" occasionally
proceeding to temporary darkening
or "white-out" of vision
Prevalent in young adults Diminution of hearing and/or
occurrence of unusual sounds
Trigger Classical (particularly a "whooshing" noise)
Pallor reported by onlookers
A-Typical/Non-classical
Benditt D. Reflex syncope in adults: Clinical presentation and diagnostic evaluation [Internet]. 2017 [cited 2017Aug26]. Available from:
https://www.uptodate.com/contents/reflex-syncope-in-adults-clinical-presentation-and-diagnostic-evaluation?source=see_linkionName=TYPES OF REFLEX
SYNCOPE&anchor=H2305727192#H2305727192
 SYNCOPE
Whats the cause?

Syncope Cathegorized into 4 causes (True syncope)

Reflex Syncope Orthostatic syncope Cardiac Arrhythmias Structural Cardiopulmonary disease

Benditt D. Syncope in adults:

Epidemiology, pathogenesis,
and etiologies [Internet]. 2017
[cited 2017Aug25]. Available
from:
https://www.uptodate.com/cont
ents/syncope-in-adults-
epidemiology-pathogenesis-
and-etiologies?
source=see_link
 SYNCOPE
Orthostatic syncope Normal and pathophysiology
Normal blood pressure response to standing

Decrease blood pressure

Volume
Medication Compensatory reflex depletion
(Baroreceptor reflex)

Increase sympathetic Medication

Autonomic failure
Reduce parasympathetic

Increase peripheral resistance Increase heart rate Increase contractility

Increase cardiac output

Increase venous return Increase preload

Clinically apparent: Decrease SBP (5-10 mmHg), Increase DBP (5-10 mmHg), Increase pulse rate (10-25 bpm)

Kaufmann H, Kaplan NM. Mechanisms, causes, and evaluation of orthostatic hypotension [Internet]. 2015 [cited 2017Aug27]. Available from:
https://www.uptodate.com/contents/mechanisms-causes-and-evaluation-of-orthostatic-hypotension?source=see_link
 SYNCOPE
Orthostatic syncope Detailed pathogenesis
Medication

Autonomic failure Orthostatic Syncope Volume depletion

Neurodegenerative disease Neuropathies Aging

Caused by: Syncnucleopathies Caused by: Caused by:
Examples: 1.Small fiber peripheral Decreased
1.Parkinson disease neuropathies baroreceptor
2.Dementia with Lewy Bodies 2.Autoimmune autonomic sensitivity
3.Multiple system atrophies (Shy-Drager impairment
Syndrome) 3.Familial dysautonomia
4.Pure autonomic failure (Bradbuy- (Riley Day Syndome)
Egglestone Syndrome)

Kaufmann H, Kaplan NM. Mechanisms, causes, and evaluation of orthostatic hypotension [Internet]. 2015 [cited 2017Aug27]. Available from:
https://www.uptodate.com/contents/mechanisms-causes-and-evaluation-of-orthostatic-hypotension?source=see_link
 SYNCOPE
Orthostatic syncope Clinical symptom

Orthostatic (postural) hypotension Postural changes Decrease SBP at least 20 mmHg

OR

Decrease DBP at least 10 mmHg

Types Trigger : postural change

Standing position/
Sitting
Immediate Delayed Upright posture
Healthy More
individual worrisome Lying
Minor Occur after a
orthostatic few minutes of
hypotension postural
changes

Benditt D. Syncope in adults: Epidemiology, pathogenesis, and etiologies [Internet]. 2017 [cited 2017Aug25]. Available from: https://www.uptodate.com/contents/syncope-in-
adults-epidemiology-pathogenesis-and-etiologies?source=see_link
 SYNCOPE
Whats the cause?

Syncope Cathegorized into 4 causes (True syncope)

Reflex Syncope Orthostatic syncope Cardiac Arrhythmias Structural Cardiopulmonary disease

Benditt D. Syncope in adults:

Epidemiology, pathogenesis,
and etiologies [Internet]. 2017
[cited 2017Aug25]. Available
from:
https://www.uptodate.com/cont
ents/syncope-in-adults-
epidemiology-pathogenesis-
and-etiologies?
source=see_link
 SYNCOPE
Cardiac Arrhythmias Pathogenesis

Cardiac arrhythmia Brady/Tachy-arrhythmia Inadequate cardiac output

Inadequate mean arterial pressure

Most common causes

AV block 2nd degree Mobitz 2

High degree
AV Block
Total AV block

Sick sinus syndrome

Cardiac pause

Spontaneous recovery after

AF or atrial flutter

Benditt D. Syncope in adults: Epidemiology, pathogenesis, and etiologies [Internet]. 2017 [cited 2017Aug25]. Available from: https://www.uptodate.com/contents/syncope-in-
adults-epidemiology-pathogenesis-and-etiologies?source=see_link
 SYNCOPE
Cardiac Arrhythmias Pathogenesis
Ventricular tachycarrhythmia
Related to structural heart disease
Example: HOCM, arrhythmogenic rightt
ventricular cardiomyopathy

Ventricular bigeminy Associated with:

Hypotension
Bradycardia
Near syncope
Full syncope rare

Supraventricular tachyarrhythmia
Rarely associated with syncope
Impaired vasomotor function

Benditt D. Syncope in adults: Epidemiology, pathogenesis, and etiologies [Internet]. 2017 [cited 2017Aug25]. Available from: https://www.uptodate.com/contents/syncope-in-
adults-epidemiology-pathogenesis-and-etiologies?source=see_link
 SYNCOPE
Whats the cause?

Syncope Cathegorized into 4 causes (True syncope)

Reflex Syncope Orthostatic syncope Cardiac Arrhythmias Structural Cardiopulmonary disease

Benditt D. Syncope in adults:

Epidemiology, pathogenesis,
and etiologies [Internet]. 2017
[cited 2017Aug25]. Available
from:
https://www.uptodate.com/cont
ents/syncope-in-adults-
epidemiology-pathogenesis-
and-etiologies?
source=see_link
 SYNCOPE
Structural Cardiovascular Disease Pathogenesis

Structural cardiovascular disease Decrease cardiac output Syncope

Obstruction of outflow tract Decreased contractility Restrictive condition Channelopathies

Most common

Aortic stenosis Critically stenotic

Exercise-induced
HOCM
peripheral vasodilation

25% have syncopal episodes

Dynamic LVOT obstruction Systolic anterior motion

Benditt D. Syncope in adults: Epidemiology, pathogenesis, and etiologies [Internet]. 2017 [cited 2017Aug25]. Available from: https://www.uptodate.com/contents/syncope-in-
adults-epidemiology-pathogenesis-and-etiologies?source=see_link
 SYNCOPE
Structural Cardiovascular Disease Clinical cue

Benditt D. Syncope in adults: Epidemiology, pathogenesis, and etiologies [Internet]. 2017 [cited 2017Aug25]. Available from: https://www.uptodate.com/contents/syncope-in-
adults-epidemiology-pathogenesis-and-etiologies?source=see_link
 SYNCOPE
Clinical approach Syncope or not syncope?

Syncope or not syncope?

That is the question

First thing first

True Syncope Non-syncope

Go to next algorithm

Consult/
More workup

Guideline for the diagnosis and management of syncope

(version 2009). European Heart Journal (2009) 30, 2631
 SYNCOPE
Clinical approach
Algorithm

Mcdermott D, Quinn J. Approach to the adult patient with syncope in

the emergency department [Internet]. 2017 [cited 2017Aug27].
Available from: https://www.uptodate.com/contents/approach-to-the-
adult-patient-with-syncope-in-the-emergency-department?
source=see_link#H6