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    Syncope, More Than Symptom: Mohamed Abd El Zaher

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    ayman_fkirin
    Syncope, more than a symptom, is a common clinical problem that can be caused by various cardiac and non-cardiac issues. It accounts for 1% of hospital admissions. Vascular causes like orthostatic hypotension are most common, followed by cardiac causes especially arrhythmias. Evaluation involves detailed history, physical exam, ECG and additional testing depending on suspected cause. Prognosis depends on underlying etiology, with cardiac causes having higher mortality. Management focuses on treating the identified cause while reassuring patients with neurally-mediated syncope.

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    Syncope, More Than Symptom: Mohamed Abd El Zaher

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    ayman_fkirin
    65 views39 pages
    Syncope, more than a symptom, is a common clinical problem that can be caused by various cardiac and non-cardiac issues. It accounts for 1% of hospital admissions. Vascular causes like orthostatic hypotension are most common, followed by cardiac causes especially arrhythmias. Evaluation involves detailed history, physical exam, ECG and additional testing depending on suspected cause. Prognosis depends on underlying etiology, with cardiac causes having higher mortality. Management focuses on treating the identified cause while reassuring patients with neurally-mediated syncope.

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    Syncope

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    Syncope, more than a symptom, is a common clinical problem that can be caused by various cardiac and non-cardiac issues. It accounts for 1% of hospital admissions. Vascular causes like orthostatic hypotension are most common, followed by cardiac causes especially arrhythmias. Evaluation involves detailed history, physical exam, ECG and additional testing depending on suspected cause. Prognosis depends on underlying etiology, with cardiac causes having higher mortality. Management focuses on treating the identified cause while reassuring patients with neurally-mediated syncope.

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    Attribution Non-Commercial (BY-NC)
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    Download as ppt, pdf, or txt
    65 views39 pages

    Syncope, More Than Symptom: Mohamed Abd El Zaher

    Uploaded by

    ayman_fkirin
    Syncope, more than a symptom, is a common clinical problem that can be caused by various cardiac and non-cardiac issues. It accounts for 1% of hospital admissions. Vascular causes like orthostatic hypotension are most common, followed by cardiac causes especially arrhythmias. Evaluation involves detailed history, physical exam, ECG and additional testing depending on suspected cause. Prognosis depends on underlying etiology, with cardiac causes having higher mortality. Management focuses on treating the identified cause while reassuring patients with neurally-mediated syncope.

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    of 39

    Syncope, more than

    symptom
    Mohamed Abd El Zaher
    Lecturer of cardiology
    Ain Shams University
    2009
    Agenda
     Definition.
     Prevalence.
     Causes and classification.
     Prognosis.
     Tests for diagnosis.
     Approach for diagnosis.
     Management.
    Agenda
     Definition.
     Prevalence.
     Causes and classification.
     Prognosis.
     Tests for diagnosis.
     Approach for diagnosis.
     Management.
    Defintion
     Sudden, Transient, loss of consciousness and
    postural tone with spontaneous recovery.

    (Due to cerebral hypoperfusion and not requiring


    electrical or chemical therapy for reversal)
    (Restoration of appropriate behavior and
    orientation after a syncopal episode is usually
    immediate)
    The metabolism of the
    brain is exclusively
    dependent on perfusion.

    Consequently, cessation
    of cerebral blood flow
    leads to loss of
    consciousness within
    approximately 10
    seconds
    Syncope excludes seizures, coma, shock, or
    other states of altered consciousness.
    Agenda
     Definition.
     Prevalence.
     Causes and classification.
     Prognosis.
     Tests for diagnosis.
     Approach for diagnosis.
     Management.
    :Prevalence
    Syncope is an important clinical
    problem because it is
     Common.
     Costly.
     Often disabling.
     may cause injury.
     and may be the only warning sign before
    sudden cardiac death. (HCM, long QT,
    Brugada, ARVD)
    Syncope account for 1 % of hospital admissions
    and 3 % of emergency department visits.
    Age related prevalence

     In young individuals, NMS is the most


    common.

     syncope in elderly include orthostatic


    hypotension, medication, aortic stenosis,
    carotid sinus hypersensitivity, and
    bradyarrhythmias.
    Agenda
     Definition.
     Prevalence.
     Causes and classification.
     Prognosis.
     Tests for diagnosis.
     Approach for diagnosis.
     Management.
    Classification of syncope
    True Syncope

    (cerebral hypoperfusion)
     Vascular (Neurally
    mediated , sitiuational &
    orthostatic).
     Cardiac
    (arrhythmias,
    anatomical)
    Classification of syncope
    True Syncope Condition mimic
    syncope
    (cerebral hypoperfusion) (no cerebral hypoperfusion)
     Vascular (Neurally  Neurologic disease
    mediated , sitiuational & (Epilepsy, TIA).
    orthostatic).  Metabolic
     Cardiac (Hypoglycemia, hypoxia
    (arrhythmias, and alcohol)
    anatomical)  Psychogenic (Anxiety,
    panic, conversion reaction).
     Vascular causes of syncope are most common,
    followed by cardiac causes. (True syncope)

     Among cardiac causes of syncope,


    arrhythmias are most common.

     Neurological causes of apparent syncope are


    surprisingly uncommon, accounting for less
    than 10 % of all cases of syncope.
    Vascular causes for syncope
    I- Orthostatic Hypotension :
    Definition: 20-mmHg drop in systolic blood
    pressure or a 10-mmHg drop in diastolic
    blood pressure within 3 minutes of standing.
    Precipitating factors:
    Volume depletion.
    Vasodilators.
    Elderly (↓ baroreceptor sensitivity, ↓ cerebral
    blood flow, renal sodium wasting, and an
    impaired thirst mechanism with aging ).
    Mechanism

    800 ml of blood is displaced to the


    abdomen and lower extremities

    ↓ cop abrupt drop of the VR

    stimulation of aortic & carotid, baroreceptors

    Increase in sympathetic outflow ( VC and ↑ HR)


    :Causes of failure of this mechanism

     Drugs:

    Diuretics.
    VD.
    Alcohol
    :Causes of failure of this mechanism

     Drugs:  Autonomic failure:


    1. Primary:
    Diuretics.  Pure autonomic failure.
    VD.
     Multisystem atrophy
    (shy-dragger S).
    Alcohol 2. Secondary:
     Aging.
     CNS (MS-tumor).
     Medical (DM-CRF).
     Autoimmune (SLE,
    RHD).
    II- Reflex mediated syncope
    Trigger= Response=
    afferent efferent limb
    limb Vagal ++.
     Prolonged Symp –
    standing
     Carotid ++.
     Micturation. Bradycardia, ↓Bpr
     Syncope
    II- Reflex mediated syncope
    Trigger= Response=
    afferent efferent limb
    limb Vagal ++.
     Prolonged Symp –
    standing
     Carotid ++.
     Micturation. Bradycardia, ↓Bpr
     Syncope
    Fixed
    Variable
    A) Neurally mediated syncope:
    = neurocardiogenic, vasovagal:
    Trigger: Prolonged standing. Hot weather.
    Sight of blood. Pain.
    Response: Vasodepressor - cardioinhibitory or
    mixed.
    Mechanism: trigger ↓VR ↓CO ++BR

    ++Vagal of mechano. r ++ ++ Symp


    B) Carotid Sinus Hypersensitivity:
    Trigger:  Carotid stimulation.
    Response: the same.
    Mechanism: ++ of carotid sinus baroreceptors.
    Carotid sinus massage:
     In both the supine and upright positions.

     Gentle pressure over the carotid pulsation.

     5 to 10 seconds.

     Avoided if (bruits, recent CVS or TIA). CVS.


    For positive test:
     Pause > 3 seconds.

     >50 mmHg drop in sys Bp.

     >30 mmHg drop in sys Bp with symptoms.


    Cardiac causes for syncope
    Anatomical Arrhythmias
     MS-AS.  Brady.

     HoCM.  Tachy.

     Tamponade.

     MI.

     Ao. Dissection.

     PE.
    Agenda
     Definition.
     Prevalence.
     Causes and classification.
     Prognosis.
     Tests for diagnosis.
     Approach for diagnosis.
     Management.
    Prognosis
     Varies greatly with the diagnosis.

     Syncope of unknown origin or syncope with a


    noncardiac cause (including reflex-mediated
    syncope) is generally associated with a benign
    prognosis.

     Syncope with a cardiac cause is associated


    with up to 30 percent mortality at 1 year.
    Evaluation and diagnosis
    I- History:
     Most imp.
     Can identify up to 25% of cases.

     You can ask about:

     Syncope or mimic.  ppt factors.


     Cardiac ds.  F Hx.
     Prior attacks.
    :II- Physical examination
    .Bp. (supine & standing) *
    .Cardiac examination *
    .Neurological examination *
    :III- ECG
    .Clue for cardiac disease
    .Diagnosis of arrhythmias
    Normal ECG linked with better prognosis
    IV- Blood tests:
    (serum electrolyte, cardiac enzyme, glucose,
    and hematocrit levels, are of low diagnostic
    value.
    As a result, the routine use of laboratory tests
    is not recommended for patients with
    syncope.
    V- Continuous ECG recording:
    A- Holter:
    Suspected arrhthymias.
    Recurrent syncope.
    B- Loop recorder:
    Infrequent episode.
    Other causes excluded.
    C- Implantable event recorder:
    After full evaluation with –ve results.
    VI- Echocardiography:
    Not routine.
    If organic ht disease is suspected.

    VII- Upright tilt-table testing:


    • Gold standard for Neurally mediated syncope.

    VIII- Ex ECG:
    * Syncope occurred during or immediately
    after exertion .
    IX- EPS:
    • Arrhythmia suspected but not confirmed.

    • Differentiate between different arrhythmias.

    • High risk occupation ???.

    X- Neurological tests:
    • EEG, CT, MRI, carotid duplex.

    • rarely diagnostic, overused.

    • Consider vertebrobasilar insufficiency.


    Agenda
     Definition.
     Prevalence.
     Causes and classification.
     Prognosis.
     Tests for diagnosis.
     Approach for diagnosis.
     Management.
    Approach to the Evaluation of
    Patients with Syncope
    Agenda
     Definition.
     Prevalence.
     Causes and classification.
     Prognosis.
     Tests for diagnosis.
     Approach for diagnosis.
     Management.
    Management
    1- Treatment of the cause, <the most imp>.
     HCM….
     IHD…
     PE.
     Tamponade.
     Brady…..
     Tachy…
     ARVD, Long QT, Brugada……
    ?Should I hospitalize

    Yes, if:
    1. Suspect heart disease.
    2. Abnormal ECG.
    3. Severe injury.
    4. F hx of SCD.
    5. Syncope with exertion.
    What about neurally mediated
    ?????syncope
    1. Reassurance.
    2. Avoid PPT factors.
    3. During syncope: lie down, elevate the leg.
    4. In between attacks:
     ↑ Na++ in diet.
     Avoid dehydration.
     Physical measures is well accepted option,
    isometric hand grip, standing wall (40 min. twice
    daily).
     Drugs: (BB, midodrine and fludrocortisone).
     PPM only if (>5 episodes/yr, severe physical
    injury and age>40 yrs.
    Thank You
    Thank You

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