icm syncope

SyncopeVonny F. Goenawan

Siloam Hospital Lippo Karawaci

Definition of syncope

Transient loss of consciousness with an inability to maintain postural tone

followed by spontaneous recovery

Transient disruption of cerebral perfusion that results from decrease of cardiac output, profound vasodilation, or both

Syncope occurs due to

Accounts for 3% of ER visits

Accounts for 1-6% hospital admission

Increase incidence with advancing age

Common problem

Some causes of syncope are potentially fatal

sincope

Syncope must be differentiated from other non syncopal conditions which

cause a transient loss of consciousness

Cardiac arrthymias as a primary cause◦Bradyarrhythmias

Sinus node disease AV nodal disease Pacemaker dysfunction Drug induced

◦Tachyarrhythmias VT, torsade de pointes

Cardiac syncope

14%

Structural cardiac or cardiopulmonary disease◦ Valvular heart disease◦ Acute MI or ischemia◦ Pericardial disease/ tamponade◦ Pulmonary embolus/pulmonary hypertension◦ Obstuctive cardiomyopathy

4%

Neurally mediated reflex syncope (NM)

1. Carotid sinus syncope ( head turning, shaving)

2. Situational faint • Coughing/sneezing• GI stimulation – defecating, swallowing• Micturation

3. Vasocagal *common faint*• Also called neurocardiogenic• Often situational

Non Cardiac syncope

24%

- Upon positional change neurohormonal events maintain cerebral perfusion

- normally decreased venous return and subsequent decreased left ventricular filling

increase sympathetic tone

- - overly sensitive left ventricular response misinterpret hypercontractility as volume overload

inhibit sympathetic stimulation hypotension, bradychardia, syncope

Increased pressure in carotid sinus parasympathetic stimulation

syncope

Orthostatic Automonic failure

◦Primary autonomic dysfunction Pure autonomic failure Parkinson’s

◦Secondary autonomic dysfunction Diabetic neuropathy Drugs

◦Volume loss Internal bleeding, diarrhea

Non Cardiac Syncope

11%

Cerebrovascular Almost never the cause of true

fainting Vascular steal syndromes

Non Cardiac Syncope

Physical examination

History of syncope after head turning, shaving or while wearing a tight collar, older patients with unexplained presyncope or falls, negative cardiovascular and neurologic investigations.

With patient supine massage each carotid 5-10 secs while monitoring BP and HR

Positive response is asystole of 3 seconds or drop in systolic BP of 50 mmHg

Non spesific – 25% of nonsyncopal elderly patients will have positive response

Carotid sinus syndrome

Tilt patient passive (60 degrees, 45 minutes) in absence of pharmacologic provocation

Administer Isoprotenol, nitroglycerin, tilt again for 10 minute

Positive results reproduction of patient’s typical syncopal symptoms with hypotension, bradycardia or both

Tilt table testing

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