Icm Syncope

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SyncopeVonny F. GoenawanSiloam Hospital Lippo KarawaciDefinition of syncopeTransient loss of consciousness with an inability to maintain postural tone followed by spontaneous recoveryTransient disruption of cerebral perfusion that results from decrease of cardiac output, profound vasodilation, or bothSyncope occurs due to Accounts for 3% of ER visitsAccounts for 1-6% hospital admissionIncrease incidence with advancing ageCommon problemSome causes of syncope are potentially fatalsincopeSyncope must be differentiated from other non syncopal conditions which cause a transient loss of consciousness

Cardiac arrthymias as a primary causeBradyarrhythmiasSinus node diseaseAV nodal diseasePacemaker dysfunctionDrug inducedTachyarrhythmiasVT, torsade de pointesCardiac syncope14%Structural cardiac or cardiopulmonary diseaseValvular heart diseaseAcute MI or ischemiaPericardial disease/ tamponadePulmonary embolus/pulmonary hypertensionObstuctive cardiomyopathy4%

Neurally mediated reflex syncope (NM)Carotid sinus syncope ( head turning, shaving)Situational faint Coughing/sneezingGI stimulation defecating, swallowingMicturationVasocagal *common faint*Also called neurocardiogenicOften situationalNon Cardiac syncope24%

Upon positional change neurohormonal events maintain cerebral perfusion

normally decreased venous return and subsequent decreased left ventricular filling increase sympathetic tone

- overly sensitive left ventricular response misinterpret hypercontractility as volume overload inhibit sympathetic stimulation hypotension, bradychardia, syncopeIncreased pressure in carotid sinus parasympathetic stimulation syncopeOrthostaticAutomonic failurePrimary autonomic dysfunction Pure autonomic failureParkinsonsSecondary autonomic dysfunctionDiabetic neuropathyDrugsVolume lossInternal bleeding, diarrheaNon Cardiac Syncope11%CerebrovascularAlmost never the cause of true faintingVascular steal syndromesNon Cardiac Syncope

Physical examination

History of syncope after head turning, shaving or while wearing a tight collar, older patients with unexplained presyncope or falls, negative cardiovascular and neurologic investigations.With patient supine massage each carotid 5-10 secs while monitoring BP and HRPositive response is asystole of 3 seconds or drop in systolic BP of 50 mmHgNon spesific 25% of nonsyncopal elderly patients will have positive responseCarotid sinus syndromeTilt patient passive (60 degrees, 45 minutes) in absence of pharmacologic provocation Administer Isoprotenol, nitroglycerin, tilt again for 10 minutePositive results reproduction of patients typical syncopal symptoms with hypotension, bradycardia or both

Tilt table testing