Chap 4 Syncope

Jiaqi Zhao
Department of Cardiology,
Affiliated Hospital of
Ji ning Medical College, Ji
ning
 Outline
 Definition
 Epidemiology
 Why it’s important
 Possible causes
 Distribution of causes in community
 Clues to diagnosis
 Approach
 Definition
 Abrupt and transient loss of
consciousness
 Absence of postural tone
 Spontaneous rapid and full recovery
Incidence

Sorteriades ES, et al. NEJM. 2002

 Epidemiology
 Actual rates likely higher
 30% of young adults report prior
episode of syncope
 6% annual incidence in elderly
 Why it’s Important
 Alarming to patient, family and
clinicians
 Injuries occur in ~35% of patients1
 Accounts for 1% of hospital
admissions and 3% of ER visits2
 Annual evaluation and treatment
cost of $800M in 19993
1.
 Recurrent episodes = poor QOL4
Olshansky B. Up to Date, updated April 2005
2. Kapoor W. JAMA 1992
3. Nyman JA, et al. Pacing Clin Electr 1999
4. Linzer M, et al. J Clin Epid 1991
 Broad Causes of Syncope
 Reflex mediated
 Orthostatic hypotension
 Cardiac dysrhythmia
 Cardiac Obstruction
 Neurologic
 Metabolic
 Unexplained
 Reflex Mediated
 Neurocardiogenic (vasovagal)
 Carotid sinus hypersenstivity
 Micturition
 Cough
 Defecation
 Deglutition
 Postprandial
 Gelastic1
1. Braga SS et al. Lancet 2005
 Orthostatic
 Medication related
 Fluid depletion
 Illness/bedrest
 Dysautonomias
 Bradbury Eggleston Syndrome (pure autonomic
failure)
 Shy Drager Syndrome (multiple system
atrophy)
 Parkinsonism with autonomic failure
 Cardiac Dysrhythmia
 Bradycardias
 Sinus node disease
 AV and infranodal conduction system
disease
 Tachyarrhythmias
 SVT with accessory AV pathway
 VT with structural heart disease
 VT with no structural heart disease
 Cardiac Obstruction

 Aortic stenosis
 Atrial myxoma
 Hypertrophic cardiomyopathy with
obstruction
 Severe pulmonary hypertension
 Pulmonary embolism
 Cardiac tamponade
 Metabolic
 Hypoglycemia
 Hypoxia
 Hyperventilation
Framingham Heart Study
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Soteriades ES et al. NEJM. 2002.

Prognosis

Sorteriades ES, et al. NEJM. 2002

 Helpful Clues in History
 Age
 Context
 Pattern
 Prodrome
 Observations of witnesses
 Chronic Illnesses/known cardiac
disease
 Medications
 History, Physical and
ECG

Specific
Not a clue !!!
Clear cut mechanism
reflex mediated suspected
or
orthostatic

Dx specific Exclude fatal

testing causes
Treat

Strickberger SA et al. JACC 2006

 Potentially Fatal Causes
 Silent ischemia/unrecognized CAD
 Structural heart disease
 Impaired systolic function (low EF)
 Hypertrophic cardiomyopathy
 Arrhythmogenic right ventricular dysplasia
(ARVD)
 Primary electrical disease
 Long QT syndrome
 Brugada syndrome
 Catecholaminergic polymorphic ventricular
tachycardia
 Presence of an accessory pathway
 Syncope in Known CAD
Echo

EF <35% EF >35%

Cath +/- revascularization

ICD

EP Study

unremarkabl Unstable
e SVT/AP
monomorphic
VT Sinus node
Observe/ILR or Ablate/PPM
ICD/ablate conduction with AT Rx
dz PPM
 Syncope in HCM
 Annual risk of SCD is 0.6 to 1%
 EP studies generally not useful
 Risk factors for sudden death
 Syncope !!!
 Family history of SCD
 Frequent NSVT
 Wall thickness > 30 mm
 Genotyping not ready for prime time
 ICDs are effective
 Arrhythmogenic Right
Ventricular
Dysplasia/Cardiomyopathy
 ~20% of SCD in pts < 35 may be due
to ARVD
 30-50% are familial, others sporadic
 Present with PVCs, syncope,
sustained VT with LBBB morphology
 Utility of EP testing not established
 With ICD rx, the annual rate of
appropriate shocks is 15-20%
 ARVD

Kies P et al. J Cardiovasc Electrophysiol; 17: 586-593.

2006
Long QT Syndrome
Brugada Syndrome