Syncope

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Intro to Syncope

• Definition: Transient loss of consciousness (LOC) with a

spontaneous return to baseline

• May have loss of postural/motor tone

• Clonic jerks

• Should not last more than 1-2 minutes

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Approach to Syncope

• Work-up

• History (most important)

• CBC, BMP

• EKG

• If suspicion for structural heart disease => Echocardiogram

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Life-threatening Conditions

• Cardiac syncope (AS, HOCM, pacemaker malfunction)

• Hemorrhage (GI bleed, ruptured aortic aneurysm or ectopic

pregnancy)

• Pulmonary embolism

• Subarachnoid hemorrhage

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Syncope: High-Yield Conditions

• Vasovagal

• Situational

• Carotid sinus syndrome

• Orthostatic hypotension

• Structural heart disease

• Cerebrovascular disease

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 Vasovagal Syncope
• Presentation: Young, healthy patient w/ LOC
• Triggers:
• Prolonged standing
• Heat
• Physical activity
• Emotional stress
• Noxious/painful stimuli

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 Vasovagal Syncope
• Prodrome: Constellation of symptoms associated w/ syncopal event
• Diaphoresis
• Palpitations
• Sensation of feeling “hot” or “cold”
• “White-out” of vision
• “Whooshing sound” in the ears
• Nausea
• Pallor
• Post-recovery fatigue

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 Vasovagal Syncope
• Pathophysiology: Mixed response
• Cardioinhibitory response => ↑ Parasympathetic => Bradycardia, AV block
• Vasodepressor response => ↓ Sympathetic => Bradycardia despite hypotension
• Autonomic dysfunction

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 Vasovagal Syncope
• Dx: Clinical
• Look for classic triggers and prodromal symptoms
• Lack of postictal state
• +/- EKG

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 Vasovagal Syncope
• Mgmt: Reassurance + Patient Education
• When symptoms arise => Lay supine with legs raised
• Counterpressure techniques
• Volume support => ↑ salt intake +/- Fludrocortisone
• Avoid triggering activities
• Caution in high-risk settings

Wikicommons: PxFuel Jarie “Person Squatting”

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 Reflex Syncope
• 2 Types:

• 1. Vasovagal syncope

• 2. Situational syncope
• Defecation
• Post-micturition
• Swallow

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 Situational Syncope
• Mgmt: Patient education
• Defecation => Stool softeners
• Post-micturition => Avoid excessive fluid intake prior to bedtime

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 Carotid Sinus Syndrome
• Presentation: Older male w/ vascular disease and unexplained falls
• Triggers consistent w/ carotid hypersensitivity:
• Tight collars
• Neck movements

• Pathophysiology: Carotid sinus reflex arc

• Internal carotid artery has mechanoreceptors
• Vagus nerve => SA node and AV node
• ↓ sympathetic tone

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Carotid Sinus
Syndrome
• Dx: Carotid sinus massage

• Carotid sinus

hypersensitivity (CSH)

• HR pause > 3 seconds

• BP drop > 50 mmHg

• Syncope
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Carotid Sinus
Syndrome

• Mgmt: Dual-chamber pacemaker

• Patient education

• +/- Midodrine

CC (0): NIH

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 Orthostatic Hypotension
• Presentation: Older Pt w/ symptoms in response to postural changes
• Lightheadedness
• Fatigue
• Blurry vision
• Syncope

• Pathophysiology: ↓ baroreceptor sensitivity

• Hypovolemia, medications, neuropathy (e.g. Diabetes)

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 Orthostatic Hypotension
• Dx: “Orthostatic vitals”
• 5 minutes of resting supine
• Stand up for 5 minutes
• ≥ 20mm Hg decrease in systolic BP, AND/OR
• ≥ 10mm Hg decrease in diastolic BP

• +/- Labs indicating hypovolemia:

• ↑ BUN
• ↓ Urine Na+ (may be affected by
diuretics)

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Orthostatic Hypotension

© Adobe Stock / rumruay.

Modified.

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 Orthostatic Hypotension
• Mgmt: IV Fluids, Discontinue offending medications
• Patient education
• Counseling on rising slowly from supine
• ↑ salt and water intake
• Compression stockings
• +/- Fludrocortisone, Midodrine

© Adobe Stock / antaya.

Modified.

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 Structural Heart Disease
• Hypertrophic cardiomyopathy (HOCM)

• Aortic stenosis

• Atrial myxoma

• Pulmonary embolism

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 Cardiac Arrhythmias
• Heart block (Mobitz II or 3rd degree) => Stokes-Adams attack

• Ventricular tachycardia

• Long QT syndrome (e.g. Jervell and Lange-Nielson)

• Brugada syndrome (SCN5A mutation)

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 Cerebrovascular Disease
• Strokes and TIA
• Unlikely to cause true syncope

• Subclavian steal syndrome

• Unilateral arm pain with exertion (claudication)
• Vertigo, lightheadedness, and rarely syncope
• Atherosclerosis at proximal subclavian artery
• May also follow repair of Aortic Coarctation

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Syncope: High-Yield

• Vasovagal
• Situational
• Carotid sinus syndrome
History is key!
• Orthostatic hypotension
• Structural heart disease
• Cerebrovascular disease

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