Syncope

Symptom not adisease

Need to find underlying cause
Decrase in the global perfusion to the brain especially the brain stem
Conduit obstruction
o You have to wipe out most of cerebral circulation to cause syncope
o Obstruction of one of the arties (e.g. carotid stenosis does not
cause syncope
o Subclavian steal is a rare cause
Loss of postural tone
o Occurs when patients are upright
o Seldom when pateitns are lying flat
Not syncope if no spontaneous recovery
No residual focal neurological deficit
Reported frequency of syncope
o 1-6% patient of all hospital admissions
Causes of syncope
o Vascular 50%
Drug induced
Hypovolemia
Autonomic failure
Vasovagal
Situational (cough, micturition, defecation)
Carotid sinus hypersensitivity
o Cardiac 12%
Anatomical
Obstruction
Aortic stenosis
Hypertrophic cardiomyopathy
Atrial myoxoma (cardiac tumour->obstruction to
flow)
Arrhythmias
Bradyarrhythmias
Tachyarrythmias
o Neurogenic 2%
o Metabolic/miscellaneous 13%
o Unexplained causes 20%
History is very important
Distinguish from other situation where there is altered conscious
Prodrome->neutrally mediated-preceded by prodrome (related to
activity e.g. micturition, prolonged standing), associated N&V, after
exertion
Cardiac-no warning, associated chest pain etc. DURING exertion, previous
cardiac history, FH sudden death etc.
Physical examination

Signs of hypovolemia
o Blood pressure
o Postural drop
o Heart rate
o Heart sounds
o Murmurs
o Carotid sinus message
Pathology
o Haemoglobin-big drop
o Electrolytes-BSL etc
o If pacemaker present-interrogate
ECG
o Arrhythmias
o Not always present when you do ECG
o Look for evidence that it happened
o Look for substrate for arrhythmias
o Look for consequences of underlying diseases
o Exclude treatable causes
o High risk features
High degree AV Block Mobitz type 2, CHB, trifascicular
Bifasicular block
Prolonged QRS->arrhythmia
Asytpmoatic sinus brady sinus pause
Others->WPW, prolonged QT, Brugada, Q waves, NSVT,
ARVD changes
o Clinical high risk faeatures
History severe structural HD (heart disease)
Syncope during exercise or supine
Absence of prodorme or precipitants
Preceded by palps, chest pain SOB
Family history SCD
Examination obstructive cardiac disease
Syncope with trauma
BP <90 mmHg or Hct <30%
Heart is too slow
o SA node disease
Sinus bradycardia
Sinus arrest
Sinoatrial block
Carotid sinus hypersensitivity
o AV node disease
Degrees of block
Bundle branch block doesnt cause brady
Heart rate too fast
o Sinus tachycardia (normal)
o Suraventricular tachycardia
o Ventricular tachycardia
o Narrow/broad complex
Slow-fast AVNRT, no visible p waves, narrow complex tachycardia

Fast-slow AVRNT
o Retrograde P waves (visible in v2/v3)
o QRS complex->most evident in V2 v3
Torsade de pointes
o Re-entrant arrhythmia with a distinctive ecg appearance,
sometimes described as a sine wave within a sine wave
o VF
Cardiac causes
o Aortic stenosis
o Hypertrophic cardiomyopathy
Get an echo, diagnose structural heart disease
A normal echo does not exclude cardiac causes
Other investigations
o Holter monitoring
o Event monitors
o Implantable event recordres
o Tilt table test
o Signal average ECG
o Electrophysiologic studies
o Cardiac catheterisation
Treatment
o Underlying cause
o Adenosine->slows down conduction (may unmask other causes),
o LQTS->implantable defribillator, treat drugs, med
Outcome
o Depends on underlying causes
o Recurrence is common
o Driiving issues (estimates)
Simple faint no restrictions
Unexplained low risk to recur 4 weeks
Cause identified and treated 4 weeks
Unexplained, high risk recurrence and no cause found 6
months