Syncope: Evaluation and

Management
dr. Astra Dea Simanungkalit, SpS

Learning Objective
Understand definition of syncope.
Know differential diagnosis of syncope.
Know management of uncomplicated
and complicated syncope.

Definiton
Syncope is a sudden transient loss of
consciousness and postural tone with
spontaneous recovery.
Due to reduction blood flow to reticular
activating system in brain stem.
A symptom, not a disease.

Pathophysiology
Normal cerebral blood flow 50-60 ml/100 g
brain tissue (12-15% resting cardiac output)
3-3.5 ml O2/100 g tissue/min.
Decreased cardiac output or peripheral
resistance decreased cerebral perfusion
pressure.
Cardiac output: bradyarrhythmia,
tachyarrhythmia, valvular disease.
Peripheral resistance: thermal stress,
standing, low CO2.

Pathophysiology

Causes of syncope

Causes of syncope

Causes of syncope

Vasovagal syncope
Excessive autonomic reflex (vagal)
activity vasodilataion, bradycardia.
Prodromal: nausea, diaphoresis,
lightheadedness, blurred visions,
headaches, palpitations, paresthesia
and pallor.
Upright position.
Resolves immediately on supine
position.
Washed out, tired feeling after.

Other type of syncope

Carotid sinus
syncope

Rotation or turning of the head or pressure on

carotid sinus (carotid massage, shaving, tight
collar, tumour compression).
Common in age > 40

Situational
syncope

Syncope after cough, defecation

and micturition.

Glossopharing
eal Neuralgia

Syncope associated with throat

(glossopharyngeal) or facial
(trigeminal) pain.

Other type of syncope

Orthostatic
syncope

Noncardioge
nic syncope

Failure of autonomic reflex

response to compensate
venous pooling in lower
extremities.
Drug or volume depletion
After pain, fear or noxious
stimuli.
Cerebrovascular syncope: TIA,
steal syndrome

What to do?

Clinical Features

Diagnosis
History taking: associated symptoms
(pre, onset, after), cardiac disease,
metabolic disorders, neurological
disease, setting, drug, family history.
Physical examination.
ECG: rule out arrhythmias,
atrioventricular block.
Echocardiography: structural cardiac
disease.

Neurally Mediated Tests Tilt

Testing
Neurocardiogenic is suspected.
Normal: tilting reduction in venous return
baroreceptor stimulation averting
syncope.
Abnormal: tilting decreased venous return
sympathetic tone increase with
stimulation of cardiac C fibers stimulation
of medullary vassodepressor region
sudden reduction in sympathetic tone and
increase vagal tone.
Positive if original symptoms are
reproduced, drop in BP, HR or both.

Neurally Mediated Tests

Carotid sinus massage
Should be avoided in patients with carotid
bruits or a history of CVD.
Reduction of > 50 mmHg in systolic BP or
ventricular pause of > 3 seconds after 510 seconds carotid massage.

Orthostatic Test
Orthostatic hypotension associated
with syncope or presyncope.
BP measurements after 5 minutes
lying supine and each minute (3
minute) after standing.
Decrease of > 20 mmHg in SBP or
decrease SBP to < 90 mmHg.
Regardless symptoms occur or not.

When to hospitalize?

Treatment
Education
Avoidance dehydration, stress, alcohol
consumption, extremely warm environment, tight
clothing, anxiety management, coping skills.
Manoeuvres to avert syncope
Drug treatment
blockers, agonists, selective serotonin
reuptake inhibitors, fludrocortisone,
disopyramide, scopolamine, anticholinergic
agents.
Pacemakers

Seizure vs TIA vs Syncope

Seizure

TIA

Syncope

Preonset

Aura: light, smell,

nausea

Diaphoresis,
lightheadedness,
palpitations, and
pallor

Onset

Tongue biting,
frothing

Dizzines, central
vertigo

TLOC

Blue face

Perioral numbness

Pallor

Tonic/clonic of
extremities
Drop attack,
myoclonic

Diplopia,
dysarthria, limb
weakness, sensory
disturbance

Might associated with

seizure like activity

Confusional state

Symptoms

Washed out

Post onset

Aching muscle

tired

Eye deviation

Increased BP and
pulse

Decreased BP and
pulsa

Mortality
Patients with cardiac syncope had the highest
risk of death from any cause and
cardiovascular events.
Structural heart disease is a major RF for
sudden death.
Excellent prognosis:
Young healthy individuals w/o heart disease and normal
ECG.
Neurally mediated syncope.
Orthostatic hypotensipn

Recurrences
35% patients have recurrences of syncope
at 3 years of follow up, 82& occur within
the first 2 years.
Predictor: reccurent >4, psychiatric
diagnosis, age > 45 years, positive tilt
table testing (TTT).
Recurrences are nor associates with
increased mortality.

Further Readings
Eropean Society of Cardiology. Guideline on
Management (Diagnosis and Treatment) of
Syncope Update 2004. Europace
(2004)6:467-537.
Mohamed HA. Syncope: Evaluation and
Management. Libyan J Med AOP: 156-159.
Chen-Scarabelli C, Scarabelli T.
Neurocardiogenic Syncope. BMJ
2004;329:336-41.

Thank you