SWOONING AND VAPORS

Syncope and near syncope

Syncope accounts for 3% ER visits

• Syncope/pre-syncope symptoms are due to a reduction in cerebral perfusion, most often as result of decreased blood pressure.

Blood pressure is dependent on

• Cardiac output• Vascular tone• Vascular volume

Cardiac output

VASCULAR VOLUME

• Blood loss • dehydration

VASCULAR TONE

• Drugs• Neuromediated• Autonomic insuffiency• Orthostasis• Vascular disease-carotid, vertebralbasilar

CAUSES OF SYNCOPE

• Cardiac: 14% arrhythmia/ 4% mechanical• Neurologic: 10%• Neurally mediated: Vasovagal 18-25%• Orthostatic: 8-10%• Psychiatric: 2%• No clear etiology 33-45%

PROGNOSIS VARIES WITH ETIOLOGY

• Cardiac syncope Non-cardiac syncope– 25% 1 year mortality -7% 1 year mortality– 14% 1 year CSD -3% 1 year CSD

HISTORY AND PHYSICAL

• More than 50% of diagnosis should come from History and Physical

• Prior incidence?• Behavior at time of event• Symptoms prodrome?• Duration of LOC?• Mental status afterwards• Witness information?

BEHAVIOR/CONDITIONSPostural changeCoughSwallowingHead turning/neck pressureDefecationPainStrong emotionProlonged standingAt rest or with activityTremor seizure activity

Symptoms

• Nausea• Pallor• Warmth/flushed• Diaphoresis• Palpitations• Visual/hearing changes• Confusion• headache

• Duration of LOC/event seconds-hours• Mental status after postictal/washed out• Witness information

Past medical History

• Structural heart disease• Previous heart rhythm problems• Seizure history• Vascular disease• Drugs and recent changes

PHYSICAL EXAM

• Vital signs, including orthostatic blood pressures->20 mmHg drop in BP with standing

• Carotid hypersensitivity>3 sec pause, 50 mmHg asymptomatic or 30 mmHg symptomatic BP drop (up to 5 sec massage)

• Bruits• Murmur• Neurological findings

diagnostics

• ECG 5% unselected diagnostic yield– Long QT; afib/flutter; MAT; paced; VPB; V tach;

bundle branch block; LVH; Old MI;WPW; Mobitiz type II

– ECHO: 5-10 %unselected diagnostic yield– EST: activity associated symptoms– Monitor holter/event monitor– Tilt table test

NEUROCARDIOGENIC SYNCOPE

• Very common 20-25% in most series• Usually manifests by second decade of life• Abnormal reflex-mediated– Usually upright position– Trigger/prodrome– Decreased venous return; increased LV

contractility; mechanical receptor activation—leads to—vasodilatation/bradycardia—manifests as hypotension-syncope

SYCOPE DIAGNOSIS SCORING SYSTEM

• PATIENT FEATURE POINTS• Female, <42 yrs 7• Syncope/presyncope

– Headache/flushing/pain 3 for each– Nausea 2– Diaphoresis 2– Male <43 yrs 2– Prolonged orthostasis 1– Cyanosis -4– Diabetes -4– Bifasicular block -3– Chest pain with fainting -2– Postictal confusion -1– Memory of fainting -1– Score 3 or > vasovagal syncope; score 2 or less another source

NEUROCARDIOGENIC SYNCOPE

• Triggers: pain; strong emotion/stress; prolonged standing

• Situational: micturation; defication; cough; deglutation

PREDICTORS OF POOR OUTCOME IN SYNCOPE PATIENTS

• Abnormal ECG-non-specific ST or sinus tachycardia

• Prior ventricular arrhythmia >10VPB/hr; VPB pairs; multifocal VPB

• CHF history• Age >45 years (without prior history of syncope)• If 0 5% 1year arrhythmia/death• If 1 10%• If 3-4 60%

WHEN TO HOSPITALIZE

• History of chest pain• Hx of CAD, CHF, Ventricular ectopy• Evidence of CHF,AS, focal neuro defect• ECG abnl.-BBB; ischemia; MI;arrhythmia• Consider-for exertional syncope; frequent

spells; age >70 yr; orthostasis; sustained physical injury; suspected ACS