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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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