Syncope

When to worry?

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Syncope

Definition Greek synkope “to
pause”

Transient LOC and postural tone
with rapid return to normal

Vertigo & dizziness are NOT
included

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Risk stratify

Cardiogenic (30% 1 yr mort)

Non Cardiogenic (2% 1yr mort)

Cardiogenic is from underlying
disease not the syncope

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NON CARDIOGENIC

Neurocardiogenic

Orthostatic

Situational

Neurological SAH VBI

?siezure ?syncope

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Neurally mediated
Non cardiogenic syncope
T r ig g e r
s e a r c h fo r it !

a d r e n e r g ic o u t flo w
> c o n t r a c t ilit y
> R A s tre tc h re c e p t

c fib r e s t im u la t io n

> v a g a l re s p o n s e

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Non Cardiogenic

Neurocardiogenic

Typically healthy +prodromal
warning

Normal exam/ECG

Send home

Convulsive syncope occurs in this group

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Non Cardiogenic

Orthostatic

postural reflexes cannot maintain
BP

Blood loss/dehydration/drugs

Usually occurs on standing

Look for danger eg AAA/ectopic

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Non Cardiogenic

Situational

Activity prior
cough/micturate/breath hold

Common with alcohol

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Non Cardiogenic

Neurological

Uncommon cause of TRUE
SYNCOPE

SAH most common

Syncope +vertigo= VBI

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Cardiogenic

WHO?

AGE >60

IHD/Cardiomyopathy/valvular
disease

Conduction abnormalities

MI is extremely rare cause of
syncope

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Cardiogenic

OBSTRUCTIVE

ARRYTHMIAS

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Cardiogenic

OBSTRUCTIVE

Aortic stenosis/HOCM

Pulmonary Hypertension/PE

Myxomas

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Cardiogenic

ARRYTHMIAS

Brady/Tachy

SSS/ various blocks

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Cardiogenic

How to pick it?

At Risk group

Usually NO warning

Occur in any position

NO trigger

“presyncope” common in this group

ECG normal + normal echo
virtually excludes cardiac

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Cardiogenic

ADMIT who??

Unknown +elderly

recurrent

poor f/u system

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What Tests are useful?

You should have most answers
after history

You should have nearly ALL
answers after Hx+Exam

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Useful tests

ECG

Hb

HCG

??? CT

Followup Holter EPS

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TAKE HOME LIST

Identify cardiac risk group early

History+++++

ECG as screen

Exclude THE BIG FOUR

SAH/PE/ECTOPIC/AAA

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Good Articles

Evaluation &mx of syncope
Kapoor JAMA 1992,268:2553-60

Triggering Mechanisms etc etc
Kikushima J Am Coll Cardiol
1999;33::350-7

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