Syncope

AM Report6/25/10

Nicole Wilde

SyncopeCause

Not Obvious Neurally Mediated (vasovagal) 58% Cardiac Disease (arrhythmias) 23% Neurologic or Psychiatric disease 1% Unexplained 18% (41% in other studies) Syncope vs Fall vs TIA, etc…

History

Number of episodes Associated Symptoms Prodrome (Auras) Sudden Onset Position Preceding Events Duration of Symptoms Medications and PMH

Physical

Abnormal Vital SignsOrthostatics Irregular HRHeart Sounds

Neurological abnormalities Positive stool guiac

Orthostatics

ECG

Sinus Bradycardia <40 BPM or sinus pause >3 sec

Mobitz II second or third degree AV block Alternating Left and Right BBB VT or rapid paroxysmal SVT Pacemaker malfunction with pauses

Hospitalizations

Suspected or known cardiac disease ECG abnormalities arrhythmia Syncope during exercise Syncope causing severe injury Family History of Sudden Death Sudden onset of palpitations, syncope in supine

position, frequent episodes 2004 ESC Syncope Guidelines

Work Up of Syncope

Echo Severe AS, Atrial Myxoma Exercise Testing CAD, Heart Block,

Autonomic Failure ECG, Telemetry, Holter Monitoring, External

Event Recorder, Implantable Loop Recorder Carotid Sinus Massage Upright Tilt Table Test EEG and Psychiatric Evaluations EP Studies Conduction system disease

Summary

Majority of patients without heart disease with rare episodes neurally mediated syncope and confirmation with tests are not needed

Recurrent episodes carotid massage, tilt testing, and prolonged ECG

Neurological referral when autonomic failure or cerebrovascular steal suspected

EEG or carotid doppler US not recommended when syncope most likely cause for LOC

Brugada Syndrome

Sudden Cardiac Arrest ECG with pseudo RBBB and ST elevation

in leads V1-V3 Coved and saddle back appearance Provoking factors: fever, drugs, electrolyte

abnormalities, etc.

Brugada Syndrome

Brugada Syndrome

Autosomal Dominant, variable expression Mutations in SCN5A cardiac sodium

channel gene Sodium Channel blockers expose ECG

changes ICD placement