TOPIC REVIEW SYNCOPE

June 28 , 2012

..
. . . .

SYNCOPE
Syncope (Greek -- to interrupt)
Sudden transient loss of consciousness with associated loss of postural tone.

Recovery is spontaneous without neurologic deficit and without requiring electrical or chemical cardioversion.
If SBP < 70 mmHg or MAP < 40 mmHg loss of consciousness

THE SIGNIFICANCE OF SYNCOPE

The only difference between syncope and sudden death is that in one you wake up.
1

Engel GL. Psychologic stress, vasodepressor syncope, and sudden death. Ann Intern Med 1978; 89: 403-412.

THE SIGNIFICANCE OF SYNCOPE

Some causes of syncope are potentially fatal Cardiac causes of syncope have the highest mortality rates
25%

Syncope Mortality

20% 15% 10% 5% 0% Overall Due to Cardiac Causes

1 2

Day SC, et al. Am J of Med 1982;73:15-23. Kapoor W. Medicine 1990;69:160-175. 3 Silverstein M, Sager D, Mulley A. JAMA. 1982;248:1185-1189. 4 Martin G, Adams S, Martin H. Ann Emerg Med. 1984;13:499-504.

SYNCOPE A SYMPTOM, NOT A DIAGNOSIS

Underlying mechanism is transient global cerebral hypoperfusion.

Brignole M, et al. Europace, 2004;6:467-537.

SYNCOPE PATHOPHYSIOLOGY
Stroke volume Heart rate Metabolic regulation Chemical regulation Systemic vascular resistance Cardiac output

autoregulation Arterial pressure

Cerebrovascular resistance

Cerebral blood flow

Prognosis
1.0
No syncope Vasovagal and other causes Unknown cause Neurologic cause Cardiac cause

0.8

Probability of Survival

0.6

0.4

0.2

Patients with cardiac causes for syncope have a significantly increased mortality risk.
0.0 0 5 10 15 20 25

Follow-up (yr)
Figure 2. Overall Survival of Participants with Syncope, According to Cause, and Participants without Syncope. P<0.001 for the comparison between participants with and those without syncope. The category Vasovagal and other causes includes vasovagal, orthostatic, medication-induced, and other, infrequent causes of syncope.

Soteriades ES, Evans JC, Larson MG, et al. NEJM. 2002;347:878-85.

COMMON CAUSES OF SYNCOPE

In young (<35 years)
Neurally mediated Psychiatric

In middle aged (35-65 years)

Cardiac (Arrhythmic, Mechanical) Neurally mediated

In elderly (>65 years)

Cardiac (Arrhythmic, Mechanical) Orthostatic Neurally mediated

Arthur W,et al. Postgrad Med J 2001.

DIAGNOSTIC ASSESSMENT: YIELDS

(N=3411 TO 4332)
Yield (%) Initial Evaluation History, Physical Exam, ECG, Cardiac Massage Other Tests/Procedures Head-Up Tilt External Cardiac Monitoring Insertable Loop Recorder (ILR) EP Study Exercise Test EEG MRI 27 5-13 43-883-5 <2-5 0.5 0.3-0.5 No data available6 38-40

References Available

KEY QUESTIONS IN INITIAL EVALUATION

Is it a syncopal episode or other type of event? Has the etiology been determined? Is there evidence suggestive of a high risk of cardiovascular events or death* ?

KEY QUESTIONS IN INITIAL EVALUATION

Is it a syncopal episode or

other type of event?

Has the etiology been determined? Is there evidence suggestive of a high risk of cardiovascular events or death* ?

 DISTINCTION OF SYNCOPE FROM SEIZURE Favour seizure

Prolonged tonic clonic activity Stereotype Aura or short neurological warning Slow recovery

Favour Syncope
Short tonic clonic movement < 15 sec after LOC Prodrome Flaccid

Pale
Quick recovery

KEY QUESTIONS IN INITIAL EVALUATION

Is it a syncopal episode or other type of event?

Has the etiology been determined?

Is there evidence suggestive of a high risk of cardiovascular events or death* ?

SYNCOPE: ETIOLOGY
NeurallyMediated
1 Vasovagal Carotid Sinus Situational
Cough Postmicturition

Orthostatic

Cardiac Arrhythmia

Structural CardioPulmonary
4 Aortic Stenosis HOCM Pulmonary Hypertension

NonCardiovascular
5 Psychogenic Metabolic e.g. hyperventilation Neurological

2 Drug Induced ANS Failure

Primary Secondary

3 Brady
Sick sinus AV block

Tachy VT*
SVT

Long QT Syndrome

24%

11%

14% Unknown Cause = 34%

4%

12%

DG Benditt, UM Cardiac Arrhythmia Center

KEY QUESTIONS IN INITIAL EVALUATION

Is it a syncopal episode or other type of event? Has the etiology been determined?

Is there evidence suggestive of a high risk of cardiovascular events or death* ?

EVALUATION : HISTORY

Circumstances just prior to attack:

Position (supine, sitting, or standing) Activity (rest, change in posture, during or after exercise etc.)

Predisposing factors (e.g., crowded or warm places, prolonged standing, post-prandial period) and of precipitating events

ESC Guidelines for the diagnosis and management of syncope (version 2009)

During attack , end of attack, eyewitness :

Number of episode Sudden onset Prodrome Duration Way of falling (slumping or kneeling over) Skin color (pallor, cyanosis, flushing) Breathing pattern (snoring) Movements and their duration

ESC Guidelines for the diagnosis and management of syncope (version 2009)

Background:
Family history of sudden death, congenital arrhythmogenic heart disease or fainting Previous cardiac disease Neurological history (Parkinsonism, epilepsy, narcolepsy) Metabolic disorders (diabetes, etc.) Medication : Anti HT drug , anti arrhythmic drugs
ESC Guidelines for the diagnosis and management of syncope (version 2009)

DRUG-INDUCED QT PROLONGATION
Antiarrhythmics
Class IA ...Quinidine, Procainamide, Disopyramide Class IIISotalol, Ibutilide, Dofetilide, Amiodarone,

Antibiotics
Erythromycin, Pentamidine, Fluconazole, Ciprofloxacin and its relatives

Nonsedating antihistamines
Terfenadine*, Astemizole

Psychoactive Agents
Phenothiazines, Amitriptyline, Imipramine, Ziprasidone
*Removed from U.S. Market
Brignole M, et al. Europace, 2004;6:467-537.

Others
Cisapride*, Droperidol, Haloperidol

EVALUATION : PHYSICAL EXAMINATION

A number of findings on physical examination can aid in the identification of some of the common causes of syncope *

Linzer M, Yang EH, Estes NA 3rd, et al. Diagnosing syncope. Part 1: Value of history, physical examination, and electrocardiography. Clinical Efficacy Assessment Project of the American College of Physicians. Ann Intern Med 1997; 126:989

 Abnormal vital signs

: BP in supine , sitting , erect position

Disturbances in heart rhythm or breathing : HR ,rhythm ,ventilation

Cardiac auscultatory findings

: AS , PS or atrial myxoma , PHT

Physiologic maneuvers : valsalva maneuver Abnormal neurologic findings Gastrointestinal bleeding

SYNCOPE: ETIOLOGY
NeurallyMediated
1 Vasovagal Carotid Sinus Situational
Cough Postmicturition

Orthostatic

Cardiac Arrhythmia

Structural CardioPulmonary
4 Aortic Stenosis HOCM Pulmonary Hypertension

NonCardiovascular
5 Psychogenic Metabolic e.g. hyperventilation Neurological

2 Drug Induced ANS Failure

Primary Secondary

3 Brady
Sick sinus AV block

Tachy VT*
SVT

Long QT Syndrome

24%

11%

14% Unknown Cause = 34%

4%

12%

DG Benditt, UM Cardiac Arrhythmia Center

THANK YOU FOR YOUR ATTENTION