Syncope diagnostic algorithm and management MUDr Jakub Honk
Syncope diagnostic algorithm and management MUDr. Jakub Honěk Kardiologická klinika, 2. LF UK a FN Motol, Praha
Definition of syncope o Syncopeloss is a of T-LOC due to transient Transient consciousness globalcerebralhypoperfusion Global characterized by rapid onset, short = circulatory cause duration, and spontaneous complete recovery. o T-LOC – all cases of transient loss of Rapid onset consciousness Short duration regardless of the pathophysiological mechanism Spontaneous complete recovery ESC Guidelines for the diagnosis and management of syncope (version 2009): Moya et al. Eur Heart J, 2009.
Significance, epidemiology o o Risk of fall and trauma A warning signal of sudden death Mostly benign in young A common complaint – 3% of emergency visits o A fraction of patients see a doctor o Bimodal age distribution
Prognosis, significance of syncope management and diagnostics Soteriades et al. N Eng J Med, 2003.
www. escardio. org/guidelines
Classification of syncope Reflex syncope Syncope from ortostatic hypotension • Vasovagal • Situational • Carotid sinus hypersensitivity • Atypical forms • Primary ANF • Secondary ANF • Drug-induced • Volume depletion Cardiac syncope • Arrhythmia as a cause • Structural heart disease
www. escardio. org/guidelines
Initial diagnostic work-up o A thorough history n What preceded syncope, prodromes, eyewitness report, symptoms after syncope n Personal and family history, medication, recurrent syncope? o Physical exam o BP supine and standing n 5 min. supine, 1 st and 3 rd min. standing o ECG
Initial evaluation – key questions Syncope? Diagnosis? Risk? • Is it syncope? • Was diagnosis made? • Is there a high-risk profile for casrdiovascular diseases or high sudden-death risk?
Initial evaluation Suspected syncope Syncope Diagnosis made NO Diagnosis uncertain Consider other diagnosis High-risk Low risk, recurrent Low-risk, sporadic Admitt, diagnose, treat Diagnose, treat? No further work-up
www. escardio. org/guidelines
Initial evaluation Risk startification o Structural heart disease n CHD (previous MI), heart failure, aortic stenosis, HCM… o Clinical or ECG signs suggestive of arrhytmic etiology n Syncope while supine, exercising, palpitations n Family history of sudden death n Bifascicular block, ns. VT, susp. SSS, preexcitation, ↑QTc, Brugada, susp. ARVC n Age >40 + recurrent syncope (50% arrhythmia) o Severe comorbidities n Anemia, ion dysbalance
Further evaluation Diagnostic methods o Carotid massage n Pause > 3 s, BP drop > 50 mm. Hg n Unknown cause in pts. > 40 yrs o Tilt test n Reflex syncope - cardioinhibitory, vasodepresoric and mixed reaction X ortostatic hypotension n Indicated in suspected reflex syncope, unknown etiology, susp. OH, difdg. of falls, pseudosyncope…
Further evaluation Diagnostic methods o ECG monitoring n In-hospital monitoring o High-risk pts. n Holter ECG (24 h, 48 h, 7 d) o frequent syncope/presyncope n Implantable/external loop recorder (ILR) o Recurrent syncope of unknown etiology, therapyresistant epilepsy, susp. arrhytmic cause n Arrhythmia during syncope or occurrence of severe arrhythmia make diagnosis, syncope with no ECG changes rule out arrhythmic cause
Further evaluation Diagnostic methods o Electrophysiological exam n Specific indications, high suspicion not confirmed non-invasively o Echocardiography n Risk stratification, structural heart disease o Stress test o Psychiatric evaluation o Neurological evaluation
www. escardio. org/guidelines
Take home messages o Not every LOC is a syncope o Thorough history is the cornerstone o Initial evaluation makes diagnosis 2540%, risk-stratification in the rest o There is plenty of diagnostic methos, use them wisely
Therapy Indications for permanent pacing o o o o o SSS + ECG correlated symptoms SSS + abnormal CSNRT Asymptomatic pauses >6 s (SSS/AVB) AVB II Mobitz II, AVB III BBB + abnormal HV conduction Alternating BBB + unexplained syncope – risk/ILR Reflex cardio-inhibitory – „ultimum refugium“ Syncope due to hypersensitive carotid sinus
- Slides: 18