SYNCOPE

DR M L PATEL MD
DEPTT OF MEDICINE
 DEFINITION
• Syncope is the sudden transient loss of consciousness and postural tone with
spontaneous recovery.
• It occurs due to acute global impairment of cerebral blood flow.
• Loss of consciousness occurs within 10 seconds of hypoperfusion of the
reticular activating system in the mid brain.
PRESYNCOPE

• A syncopal prodrome (presyncope) is common, although loss of

consciousness may occur without any warning symptoms.

• Typical presyncopal symptoms include dizziness, light headedness or

faintness, weakness, fatigue, and visual and auditory disturbances.
TRANSIENT LOSS OF CONSCIOUSNESS(TLOC)
INCIDENCE
• Individuals <18 yrs

• Military Population 17- 46 yrs

• Individuals 40-59 yrs

• Individuals >70 yrs

 MORTALITY
• Some causes of syncope are potentially fatal.
• Cardiac causes of syncope have the highest mortality rates.

Syncope
mortality
THE BARORECEPTOR
REFLEX
 MECHANISM AND PHYSIOLOGY
• Typically cerebral blood flow ranges from 50 to 60 mL/min per 100 g brain
tissue and remains relatively constant over perfusion pressures ranging from 50
to 150 mmHg.
• Cessation of blood flow for 6–8 seconds will result in loss of consciousness,
while impairment of consciousness ensues when blood flow decreases to 25
mL/min per 100 g brain tissue.
• From the clinical standpoint, a fall in systemic systolic blood pressure to ~ 50
mmHg or lower will result in syncope.
• A decrease in cardiac output and/or systemic vascular resistance—the
determinants of blood pressure—thus underlies the pathophysiology of
syncope.
 CAUSES OF SYNCOPE
NEURALLY MEDIATED SYNCOPE ORTHOSTATIC HYPOTENSION

VASOVAGAL SITUATIONAL PRIMARY SECONDARY

SYNCOPE REFLEX SYNCOPE AUTONOMIC AUTONOMIC
• Provoked fear • Cough syncope FAILURE FAILURE
• sneeze syncope • Parkinson’s disease • Diabetes,
• Pain • Postmicturition • Lewy body dementia
syncope • Pure autonomic failure • Hereditary amyloidosis,
• Anxiety
• Swallow syncope • Multiple system • Primary amyloidosis
• Intense emotion • Defecation syncope atrophy
• Carotid sinus • Drug-induced • HIV neuropathy
• Sight of blood
sensitivity • Volume depletion
• Unpleasant • carotid sinus massage
odors • ocular examination
 CARDIAC SYNCOPE

ARRHYTHMIAS CARDIAC STRUCTURAL DISEASE

• Sinus node dysfunction • Valvular disease

• Atrioventricular dysfunction • Myocardial ischemia

• Supraventricular tachycardias • Obstructive and other

• Ventricular tachycardias cardiomyopathies

• Inherited channelopathies • Atrial myxoma

• Pericardial effusions and tamponade
INITIAL EVALUATION
CLINICAL HISTORY:
• Mode of onset
• Duration of episode
• Precipitating factors (triggers)
• How was consciousness regained?
• Associated factors- before (prodromes, aura), during , and after (postictal)
• Predisposing factors
• Family history.
Clinical features suggestive of reflex syncope
• Long history of recurrent syncope, in particular occurring before the age
of 40 years
• After unpleasant sight, sound, smell, or pain.
• Prolonged standing.
• During meal.
• Being in crowded and/or hot places.
• Autonomic activation before syncope: pallor, sweating, and/ or
nausea/vomiting.
• With head rotation or pressure on carotid sinus (as in tumours, shaving,
tight collars).
• Absence of heart disease.
Clinical features suggestive of orthostatic
hypotension
• While or after standing.
• Prolonged standing.
• Standing after exertion.
• Post-prandial hypotension.
• Temporal relationship with start or changes of dosage of vasodepressive
drugs or diuretics leading to hypotension.
• Presence of autonomic neuropathy or parkinsonism.
Clinical features suggestive of cardiac syncope
• During exertion or when supine.
• Sudden onset palpitation immediately followed by syncope.
• Family history of unexplained sudden death at young age.
• Presence of structural heart disease or coronary artery disease.
• ECG findings suggesting arrhythmic syncope-
Persistent sinus bradycardia <40 b.p.m. or sinus pauses >3 s in the awake state and in the
absence of physical training.
• Mobitz II second- and third-degree AV block.
• Alternating left and right BBB.
• VT or rapid paroxysmal SVT.
Mode of onset:
• Rapid sudden onset in cardiac and vasovagal syncope and seizure disorder.
• Gradual onset in hypoglycemia, during related syncope and hyperventilation.
• Unrelated to posture: arrythmogenic and seizure disorder.
- prolong standing facilitates vasovagal syncope.
- after arising: in orthostatic hypotension.
- syncope on changing position ( from sitting to lying, bending, turning over in
bed).
Duration of episode:
• In syncope, duration of the event is usually ≤1 min and duration of episode
usually lasts ≤ 5 min; while seizure, the duration of unconsciousness is
usually ≥ 5 min.
Restoration factors:
• Regained consciousness promptly in syncope ( of cardiac origin); while in
seizure disorder, it occurs slowly.
Trigerring factors:
• On exertion: cardiac syncope occurs due to left ventricular outflow
obstruction (AS,HCOM),RVOTO(PH,PE), CAD and sometimes due to
arrythmias.
• With arm exercise: subclavian steal syndrome.
• After exercise in well trained athletes: exercise induced syncope.
• With head rotation /pressure on carotid sinus: carotid sinus syncope /
hypersensitivity.
• Pain, grief, emotional stress, unpleasant sight, sound or smell: vasovagal
syncope.
• During or immediately after micturition , defecation, swallowing, coughing:
situational syncope.
Associations:
• Prodromes of warmth, nausea, sweating, light headiness: occur in vasovagal
syncope.
• Sweating or nausea before the event sometimes in cardiac syncope.
• Preceded by vertebrobasilar symptoms such as vertigo, diplopia, dysarthria,
ataxia: CVA in vertebrobasilar system.
• Episode associated with cyanosis, frothing at the mouth, tongue biting,
urinary incontinence, convulsive movements in seizure disorders.
EVALUATION contd.
PHYSICAL EXAMINATION
• BP measurement for detection of orthostatic hypotension: supine BP and
heart rate are measured after the pt. has been lying down for at least for 5
min.
• Standing measurements should be obtained immediately and for at least for 2
min., and should be continued for 10 min when there is a high suspicion of
orthostatic hypotension.
• Syncope due to OH is confirmed when there is a fall in systolic BP from a
baseline value >_20 mmHg, diastolic BP >_10 mmHg, or a decrease in
systolic BP to <90 mmHg that reproduces spontaneous symptoms
OTHER ADDITIONAL EXAMINATIONS:
• ECG monitoring: when there is a suspicion of arrhythmic syncope.
• Echocardiogram: when there is previous known heart disease, data suggestive
of structural heart disease, or syncope secondary to cardiovascular cause.
• Carotid sinus massage (CSM): in patients aged >40 years.
• Head-up tilt testing: when there is suspicion of syncope due to OH or reflex
syncope.
• Blood tests : Hb levels when haemorrhage is suspected, oxygen saturation and
blood gas analysis when hypoxia is suspected, troponin when cardiac ischaemia-
related syncope is suspected, or D-dimer when pulmonary embolism is
suspected, etc.
 DIFFERENTIAL DIAGNOSIS
Disorders without impairment of consciousness
• Falls
• Drop attacks
• Cataplexy
• Psychogenic pseudo-syncope
• Transient ischemic attacks
Disorders with loss of consciousness
• Metabolic disorders
• Epilepsy
• Intoxications
• Vertebrobasilar transient ischemic attacks
TREATMENT
 MANAGEMENT IN EMERGENCY
• It is recommended that patients with low-risk features, likely to have
reflex or situational syncope or syncope due to OH, are discharged
from the ED.
• It is recommended that patients with high-risk features receive an early
intensive prompt evaluation in ED observation unit (if available), or
are hospitalized.
• It is recommended that patients who have neither high- nor low-risk
features are observed in the ED or in a syncope unit instead of being
hospitalized.
Treatment of Reflex Syncope-
• Explanation of the diagnosis, provision of reassurance, and explanation of
the risk of recurrence and the avoidance of triggers and situations.
• Cardiac pacing is not indicated in the absence of a documented
cardioinhibitory reflex.
Treatment of Orthostatic Hypotension-
• Explanation of the diagnosis, provision of reassurance, and explanation of
the risk of recurrence and the avoidance of triggers and situations.
• Adequate hydration and salt intake are indicated.
• Modification or discontinuation of hypotensive drug regimens should be
considered.
• Midodrine or fludrocortisone if symptoms persists.
 Treatment of Cardiac Syncope-
• Cardiac pacing is indicated when there is an established relationship between
syncope and symptomatic bradycardia.
• Cardiac pacing is indicated in patients with intermittent/paroxysmal intrinsic
third- or second-degree AV block.
• Cardiac pacing is indicated in patients with syncope, BBB, and a positive EPS or
AV block.
• Catheter ablation is indicated in patients with syncope due to SVT or VT in order
to prevent syncope recurrence.
• An ICD is indicated in patients with syncope due to VT and ejection fraction
<_35%.