SYNCOPESYNCOPESYNCOPESYNCOPE

Rasim Enar, M.D.Professor of Cardiology

İstanbul University – Cerrahpaşa Medical FacultyDepartment of Cardiology

Rasim Enar, M.D.Professor of Cardiology

İstanbul University – Cerrahpaşa Medical FacultyDepartment of Cardiology

Neuro- Cardiogenic SyncopeNeuro- Cardiogenic SyncopeNeuro- Cardiogenic SyncopeNeuro- Cardiogenic Syncope

Syncope - Definition

• Syncope; is a transient loss of conciousness and postural tone with spontaneous recovery

• Loss of consiousness is a result of , sudden and shorterm serebral hipoperfusion

• Restoration of conciousness or orientation after a syncopal episode is usually immediate, and does nor require electrical or chemical therapy for reversal

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• 1- 6 % of all hospital admissions

• 3 % of Emergency Department visits

Prognosis – 1 year mortality risc

• Cardiogenic Syncope : 24 % • Non-Cardiogenic Syncope : 4 %

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Prevelans

Etiology – Cardiac Causes

Anatomic causes Arrhythmic causesAortic stenosis

HOCM

Myocardial ischemia / infarction

Aortic dissection

Cardiac tamponade

Atrial myxoma

Severe pulmonary hypertension

Severe pulmonary emboli

Subclavian steal syndrome

Fallot tetralogy

Tachy-arrhythmias

- Supraventricular tachycardia

- Ventricular tachycardia

- Long-QT syndrome (primary /secondary)

- Brugada syndrome

Brady-arrythmia

- Atrioventricular block

- Pace-maker dysfunction

- ICD dysfunction

- Sinus node dysfunction / bradycardia

Sick Sinus Syndrome

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“Primary Evaluation”

• Detailed clinical history obtained from the patient or the witness of the syncopal episode, about the period just before or after the episode will give clues about the etiology

• Ortostatic blood pressure measurements and careful physical examination including oscultation of cardiac murmurs and carotis bruits

• Standart ECG

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Classification of syncope

• Neurocardiogenic syndromes e.g. vasovagal, carotid sinus hypersensitivity, situational

• Ortostatic

• Primary cause : cardiac arrhythmia – conduction disturbances

e.g. Bradycardia, Tachycardia, AV-Block, etc

• Structural cardiac or cardiopulmonary diseases

e.g. acute myocardial infarction, aortic dissection, acute pulmonary emboli, etc

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Non-syncope seizures

• Syncope-like conditions, with loss or impairment of consciousness e.g. epileptic seizures, TIA, etc

• Syncope-like conditions, where the patient is conscious e.g. Psycogenic syncope (histerical, somatization disorders), etc

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Clinical features associated with non-syncope seizure

• Post-seizure >5 min confusion (epileptic seizure)

• Long lasting tonic-clonic movements with the onset of the seizure

(epileptic seizure)

• Frequent somatic complaints without accompanying organic heart disease

(psycogenic)

• Vertigo, dizartria, diplopia (Transient Ischemic Attack)

Diagnostic Criteria – Certain (I)

Vasovagal syncope; Syncope with typical prodromal symptoms which is provoked with fear, severe pain, emotional stress, catheter instrumentation, or after prolonged standing in hot enviorement

Situational syncope; Syncope produced with vagal stimuli, like diüresis, frequeny coughing, defecation or swollowing

Ortostatic syncope; Syncope or presyncope associated withg documented ortostatic hipotension (Sudden fall of SBP > 20 mmHg or < 90 mmHg)

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Syncope secondary to cardiac ischemia; ECG documentation of acute ischemia or infarction

Syncope secondary to cardiac arrhythmia ; ECG documentation of

• Sinüs bradycardia (< 40 beat/min or repetitive sinoatrial block or sinus pause > 3 second)

• Atrioventriküler block (2nd degree Mobitz Type II or 3rd degree)• Alternating LBBB or RBBB• Rapid paroxismal supraventricular tachycardia or ventricular

tachtcardia• Pace-maker dysfunction associated with cardiac pause

Diagnostic Criteria – Certain (II)

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June 2004

Diagnostic Criteria - Probable

Conditions related with CARDIAC syncope ;

• Supine• Post egzersize• Post palpitation• Known serious organic heart disease• ECG disturbances

- wide QRS complex (>0.12 sec)- AV conduction disturbances- Post-meal at 1 hour- Post egzersize - Following with new drug administration or

after change of the dose

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Which patients should be hospitalised

• Syncope secondary to a cardiac pathology

• Syncope resulted with serious injury

• Frequent syncope attacks

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Diagnostic Tests

• Carotid Sinus Massage

• Tilt Table Test

• Holter monitorörization

• Echocardiyography

• Egzersize Test

• External or Internal Loop Recorders

• Electrophysiologic Study (EPS)

• Cardiac Catheterisation and coronary anjiography

• Neurologic and pschchiatric evaluation

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Syncope (unknown etiology)

Probable Diagnosis (10%)

Unclassified syncope (60%)

Definite Diagnosis (10%)

History, Physical Exam, ECG

EchocardiographySpesific tests Spesific treatment & F/U

Organic Heart Disease / Arrhythmia ? Vazovagal syncope ?

EPS Tilt Table Test

Diagnosis (+) Diagnosis (-) Diagnosis (+) Diagnosis (-)

Spesific tx & F/U Spesific tx & F/UHolter / Tilt TT Holter / Tilt TT

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Olası

TEŞHİS (-)

OLASI (?)

SENKOP Hikaye,FM, EKG

TEŞHİS (+)

OLASI SENKOP

Azalmış Kalp Debisi (SĞV,SV çıkış yolu obstrüksdiyonu,Mİ.

Ekokardiyografi: Kardiyak katereizasyon, CPK-MB,gelişte, Akc görüntüleme, pulmoner anjiyo.

SSS hastalığı (TİA,subklavyan çalma, migren, nöbet olasılığı, fokal nörolojik bulgular.

EEG, Serebral CT, Serebral aklım çalışması, Anjiyografi.

Karotis-sinüs Senkopu

Karotis masajı

Pulmoner Emboli emboli

BİR EPİSOD:

Tilt-testi.

?Holter.

TEKRARLAYAN SENKOP:

Tilt-test Psikiyatrik

tetkik. Holter. Loop-

kaydedici.

Kalp hastalığı (+)

Holter mont.

EFÇ: (-).

Tilt-

testi

Kalp hastalığı (-) NEGATİF