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Chap 4 SyncopeSyncope
Jiaqi Zhao
Department of Cardiology,
Affiliated Hospital ofJi ning Medical College, Ji
ning
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OutlineOutline
DefinitionDefinition
EpidemiologyEpidemiology
Why its importantWhy its important
Possible causesPossible causes
Distribution of causes in communityDistribution of causes in community Clues to diagnosisClues to diagnosis
ApproachApproach
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DefinitionDefinition
Abrupt and transient loss ofAbrupt and transient loss of
consciousnessconsciousness
Absence of postural toneAbsence of postural tone Spontaneous rapid and full recoverySpontaneous rapid and full recovery
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IncidenceIncidence
Sorteriades ES, et al. NEJM. 2002
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EpidemiologyEpidemiology
Actual rates likely higherActual rates likely higher
30% of young adults report prior30% of young adults report prior
episode of syncopeepisode of syncope 6% annual incidence in elderly6% annual incidence in elderly
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Why its ImportantWhy its Important
Alarming to patient, family andAlarming to patient, family andcliniciansclinicians
Injuries occur in ~35% of patientsInjuries occur in ~35% of patients11
Accounts for 1% of hospitalAccounts for 1% of hospitaladmissions and 3% of ER visitsadmissions and 3% of ER visits22
Annual evaluation and treatmentAnnual evaluation and treatmentcost of $800M in 1999cost of $800M in 199933
Recurrent episodes = poor QOLRecurrent episodes = poor QOL441. Olshansky B. Up to Date, updated April 20052. Kapoor W. JAMA 1992
3. Nyman JA, et al. Pacing Clin Electr 1999
4. Linzer M, et al. J Clin Epid 1991
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Broad Causes of SyncopeBroad Causes of Syncope
Reflex mediatedReflex mediated
Orthostatic hypotensionOrthostatic hypotension
Cardiac dysrhythmiaCardiac dysrhythmia
Cardiac ObstructionCardiac Obstruction
NeurologicNeurologic MetabolicMetabolic
UnexplainedUnexplained
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Reflex MediatedReflex Mediated
Neurocardiogenic (vasovagal)Neurocardiogenic (vasovagal)
Carotid sinus hypersenstivityCarotid sinus hypersenstivity
MicturitionMicturition CoughCough
DefecationDefecation
DeglutitionDeglutition PostprandialPostprandial
GelasticGelastic11
1. Braga SS et al. Lancet 2005
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OrthostaticOrthostatic
Medication relatedMedication related
Fluid depletionFluid depletion
Illness/bedrestIllness/bedrest DysautonomiasDysautonomias
Bradbury Eggleston Syndrome (pure autonomicBradbury Eggleston Syndrome (pure autonomic
failure)failure)
Shy Drager Syndrome (multiple systemShy Drager Syndrome (multiple system
atrophy)atrophy)
Parkinsonism with autonomic failureParkinsonism with autonomic failure
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Cardiac DysrhythmiaCardiac Dysrhythmia
BradycardiasBradycardias Sinus node diseaseSinus node disease
AV and infranodal conduction systemAV and infranodal conduction systemdiseasedisease
TachyarrhythmiasTachyarrhythmias
SVT with accessory AV pathwaySVT with accessory AV pathway VT with structural heart diseaseVT with structural heart disease
VT with no structural heart diseaseVT with no structural heart disease
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Cardiac ObstructionCardiac Obstruction
Aortic stenosisAortic stenosis
Atrial myxomaAtrial myxoma
Hypertrophic cardiomyopathy withHypertrophic cardiomyopathy with
obstructionobstruction
Severe pulmonary hypertensionSevere pulmonary hypertension
Pulmonary embolismPulmonary embolism
Cardiac tamponadeCardiac tamponade
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Framingham Heart StudyFramingham Heart Study
0
5
10
15
2025
30
35
40
Cardia
c
Unkn
own
Stroke
/TIA
Seizu
re
Vaso
vagal
Orthos
tatic
Medic
atio
n
Othe
r
Soteriades ES et al. NEJM. 2002.
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PrognosisPrognosis
Sorteriades ES, et al. NEJM. 2002
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Helpful Clues in HistoryHelpful Clues in History
AgeAge
ContextContext
PatternPattern
ProdromeProdrome
Observations of witnessesObservations of witnesses Chronic Illnesses/known cardiacChronic Illnesses/known cardiac
diseasedisease
MedicationsMedications
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History, Physical andECG
Clear cut
reflex mediatedor
orthostatic
Treat
Specific
mechanism
suspected
Dx specifictesting
Not a clue !!!
Exclude fatalcauses
Strickberger SA et al. JACC 2006
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Potentially Fatal CausesPotentially Fatal Causes Silent ischemia/unrecognized CADSilent ischemia/unrecognized CAD Structural heart diseaseStructural heart disease
Impaired systolic function (low EF)Impaired systolic function (low EF)
Hypertrophic cardiomyopathyHypertrophic cardiomyopathy Arrhythmogenic right ventricular dysplasiaArrhythmogenic right ventricular dysplasia
(ARVD)(ARVD)
Primary electrical diseasePrimary electrical disease
Long QT syndromeLong QT syndrome Brugada syndromeBrugada syndrome Catecholaminergic polymorphic ventricularCatecholaminergic polymorphic ventricular
tachycardiatachycardia
Presence of an accessory pathwayPresence of an accessory pathway
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Syncope in Known CADSyncope in Known CAD
Echo
EF 35%
ICD Cath +/- revascularization
EP Study
monomorphicVT
ICD/ablate
Sinus nodeorconduction
dz PPM
UnstableSVT/AP
Ablate/PPMwith AT Rx
unremarkable
Observe/ILR
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Syncope in HCMSyncope in HCM
Annual risk of SCD is 0.6 to 1%Annual risk of SCD is 0.6 to 1% EP studies generally not usefulEP studies generally not useful Risk factors for sudden deathRisk factors for sudden death
Syncope !!!Syncope !!! Family history of SCDFamily history of SCD
Frequent NSVTFrequent NSVT Wall thickness > 30 mmWall thickness > 30 mm Genotyping not ready for prime timeGenotyping not ready for prime time
ICDs are effectiveICDs are effective
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Arrhythmogenic RightArrhythmogenic Right
VentricularVentricular
Dysplasia/CardiomyopathyDysplasia/Cardiomyopathy ~20% of SCD in pts < 35 may be due~20% of SCD in pts < 35 may be due
to ARVDto ARVD
30-50% are familial, others sporadic30-50% are familial, others sporadic Present with PVCs, syncope,Present with PVCs, syncope,
sustained VT with LBBB morphologysustained VT with LBBB morphology
Utility of EP testing not establishedUtility of EP testing not established With ICD rx, the annual rate ofWith ICD rx, the annual rate of
appropriate shocks is 15-20%appropriate shocks is 15-20%
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ARVDARVD
Kies P et al. J Cardiovasc Electrophysiol; 17: 586-593.2006
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Long QT SyndromeLong QT Syndrome
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Brugada SyndromeBrugada Syndrome
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