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Cardiogenic Syncope

Syncope consists of a sudden loss of consciousness leading to an inability to preserve postural tonus. The episode is self-limited. Cardiogenic syncope may arise in a wide variety of heart conditions and may predict an ulterior catastrophic event in some cases.


Presentation

An individual that has experienced a cardiogenic syncope may describe the presence of an aura prior to the event, consisting of dizziness, amaurosis, diaphoresis, nausea or blurred vision. The duration of the aura is different in various cases, depending on the mechanism of the disease. If the substrate is arrhythmic, the aura lasts for about 3 seconds, whereas in vasovagal episodes its duration may be as long as 2.5 minutes. This period is followed by a complete, short duration loss of consciousness. Convulsions, myoclonic jerks or tonic spasms caused by brain hypoperfusion [1] may occur during the episode. Urine and fecal matter loss, confusion and oral trauma suggest epilepsy, whereas dysarthria and focal neurologic signs imply cerebrovascular disease. The recovery after a cardiogenic syncope is usually complete and spontaneous.

Failure to Thrive
  • We report an 18 month-old girl who presented with recurrent syncope as well as dyspnea, failure to thrive, and frequent episodes of pulmonary infections, suggesting congestive heart failure.[ncbi.nlm.nih.gov]
Dizziness
  • Vertigo, dizziness, and imbalance rank amongst the most common presenting symptoms in neurology, ENT, geriatric medicine, and general practice.[books.google.com]
  • dizziness,? which generally refers to an alteration in balance, vision, or perception of the environment, without the loss of consciousness.[dysautonomiainternational.org]
  • The most important imitators of epileptic seizures are dizziness, vertigo, syncope, complicated migraine; and somewhat less frequently sleep disorders, transient cerebral ischemia, paroxysmal movement disorders, endocrine or metabolic dysfunction, delirium[books.google.com]
  • An individual that has experienced a cardiogenic syncope may describe the presence of an aura prior to the event, consisting of dizziness, amaurosis, diaphoresis, nausea or blurred vision.[symptoma.com]
  • I went to Doc’s that afternoon and in just one adjustment my dizziness subsided! He sent me for a massage, where his staff eased a lot of the pain and the headache. I was amazed and so thankful!”[bakerchiropractic.org]
Seizure
  • There are chapters on epileptic seizures that do not look like typical epileptic seizures, and conversely, apparent epileptic seizures that are not.[books.google.com]
  • Repeated generalized seizures induce time-dependent changes in the behavioral seizure response independent of continued seizure induction. J Neurosci 1997 ;17: 5581 - 5590 3. Scotti AL, Bollag O, Nitsch C.[nejm.org]
  • After reviewing the ECG during the video-EEG recording, cardiogenic syncope, resulting from a cardiac arrhythmia, was identified as the cause of the seizures.[ncbi.nlm.nih.gov]
  • However, simultaneous ECG-EEG recording of a tonic seizure could not be obtained.[jnnp.bmj.com]
  • During fainting, "seizure-like" activity may occur. This shaking or stiffening is thought to be distinct from a true seizure and is due to the brain being briefly deprived of oxygen and blood flow. Patients often feel unwell after fainting.[pccoforegon.com]
Insomnia

Workup

A careful history inquiry is a key tool in evaluating a syncope patient [2]. It should always be combined with clinical examination and a 12 lead electrocardiogram (class A recommendations [3]). The victim should be asked about the position of the body before symptoms set in [4] [5], the activity he or she was involved in and other precipitating factors. Anamnesis should determine if the person has a history of myocardial infarction, structural heart disease, arrhythmia, channelopathy or cardiomyopathy. Prior medication (diuretics, beta blockers, vasodilators, nitrates, antiarrhythmic, tricyclic antidepressants) is always important to know.

The physical evaluation must highlight the vital signs and heart auscultation. Tachycardia is suggestive for an acute cardiovascular event, such as a myocardial infarction, pulmonary embolism or signifies an ongoing tachyarrhythmia. An acute coronary syndrome may also be accompanied by bradycardia, especially if a cardiac conduction defect is present. Murmurs also point to a cardiac cause of the syncope but do not warrant it. Cardiovascular evaluation should be completed by assessment of the jugular veins, auscultation of lung rales, palpation of the liver and possible abdominal masses signifying abdominal aneurysms and evaluation of peripheral edema.

A Schellong test is a useful maneuver, indicating orthostatic hypotension if positive. A carotid sinus massage should only be performed by an experienced physician since it can induce prolonged cardiac pauses or severe bradycardia. The maneuver is to be avoided if carotid bruits are present.

Multiple recurrences during a short period of time require immediate cause diagnosis and therapeutic intervention.

Blood workup is nonspecific in this disease, but certain tests may show predisposing factors for a cardiogenic syncope: abnormal electrolytes levels, heart enzymes or B-type natriuretic peptide [6]. An echocardiography is indicated when mechanical cardiac causes are suspected, whereas an electrocardiogram is useful in all cardiogenic syncope patients. A normal aspect implies good prognosis, but clinical judgment may still dictate the need for Holter monitoring or loop event recording [7]. The standard electrocardiogram may show atrioventricular blocks of various degrees [8], Brugada syndrome, Wolff-Parkinson-White syndrome or acute ischemia. Sinus pauses, sustained and nonsustained ventricular tachycardia episodes may also be substrates for a cardiogenic syncope. A positive tilt table test indicates a vasodepressor mechanism.

Liver Biopsy
  • He performed a liver biopsy, which again was out of pocket, and discovered I had Stage 1 liver cancer. Now, I consider myself blessed that this was discovered, but again, I had no insurance.[wholewashington.org]

Treatment

  • […] of episodes Predictability of episodes Comorbid disease Based on Treatment Evidence for treatment effectiveness Compliance with treatment Demonstrated Stability No episodes during period of surveillance Risk assessment protocol for significant syncope[casa.gov.au]
  • The one-lead ECG during video-EEG monitoring is a key component, which may allow correct diagnosis and treatment.[ncbi.nlm.nih.gov]
  • Only one patient in this study requested treatment discontinuation due to side effects.[uspharmacist.com]
  • We describe their improvement in symptoms related to neurocardiogenic syncope during treatment with ovarian hormone therapy prescribed to treat their menstrual irregularities.[pediatrics.aappublications.org]
  • Despite the significant advances in the treatment of cardiovascular diseases over the past decades, cardiogenic syncope continues to be associated with a significantly worse prognosis when compared with non-cardiogenic syncope.[ncbi.nlm.nih.gov]

Prognosis

  • Prior studies about the prognosis of syncopal patients shows that the 1-year mortality is consistently higher in cardiogenic than in non-cardiogenic or unexplained syncope.[ncbi.nlm.nih.gov]
  • An echocardiogram performed by an experienced cardiologist would facilitate the diagnosis considerably and an excellent prognosis can be achieved via surgical resection of the obstructing membrane.[ncbi.nlm.nih.gov]
  • Keywords Syncope Prognosis Cardiogenic syncope Emergency department This is a preview of subscription content, log in to check access. Notes Conflict of interest None. References 1.[link.springer.com]
  • A normal aspect implies good prognosis, but clinical judgment may still dictate the need for Holter monitoring or loop event recording.[symptoma.com]
  • Prognosis Not all cases of neurocardiogenic syncope can be avoided and there is no cure for the condition. However, there are things a person can do to help limit the number of episodes they may experience.[eatingdisorders.com]

Etiology

  • The reality is that the majority of syncopal episodes have a cardiovascular etiology. The most prominent cause is due to structural or ischemic heart disease leading to bradyarrhythmias and tachyarrhythmias.[eplabdigest.com]
  • […] either with momentary premonitory symptoms or without warning, due to cerebral anemia caused by ventricular asystole , extreme bradycardia , or ventricular fibrillation . neurocardiogenic syncope a particularly serious type of vasovagal attack ; the etiology[medical-dictionary.thefreedictionary.com]
  • Thorough histories and physical examinations are necessary to rule out any cardiac, neurologic, or other etiologies. In most cases (up to 50%), patients who experience syncope have no exact cause despite comprehensive evaluation.[uspharmacist.com]
  • Pathophysiology of neurocardiogenic syncope But the etiology of this condition is already described that neurogenic hypotension causes the syncope. Therefore, avoid the risk factors which can trigger the hypotension and syncope is followed.[medicalfoxx.com]
  • Objectives List the cardiac etiologies of syncope. Differentiate between the various cardiac etiologies of syncope. Discuss the treatment of syncope of cardiac etiology.[emsworld.com]

Epidemiology

  • Epidemiology and prognostic implications of syncope in young competing athletes. Eur Heart J 2004;25:1749-53.[acc.org]
  • Epidemiologic features of isolated syncope: the Framingham study. Stroke . 1985;16:626-629. 10. Kapoor WN. Syncope. N Engl J Med . 2000;343:1856-1862. 11. Grubb BP. Neurocardiogenic syncope. N Engl J Med . 2005;352:1004-1010. 12.[uspharmacist.com]
  • […] noninvasive risk stratification techniques for identifying patients at risk for sudden cardiac death: a scientific statement from the American Heart Association Council on Clinical Cardiology Committee on Electrocardiography and Arrhythmias and Council on Epidemiology[link.springer.com]
  • Colivicchi F, Ammirati F, Santini M (2004) Epidemiology and prognostic implications of syncope in young competing athletes. Eur H Journal 25:1749–1753 CrossRef Google Scholar 7.[link.springer.com]
Sex distribution
Age distribution

Pathophysiology

  • The elusive pathophysiology of neurally-mediated syncope. Circulation . 2000 ; 102 : 2898–2906. Crossref Medline Google Scholar 13 Kosinski D, Grubb BP, Temesy-Armos P. Pathophysiology aspects of neurocardiogenic syncope.[circ.ahajournals.org]
  • Pathophysiology of neurocardiogenic syncope But the etiology of this condition is already described that neurogenic hypotension causes the syncope. Therefore, avoid the risk factors which can trigger the hypotension and syncope is followed.[medicalfoxx.com]
  • Basic Pathophysiology Performance of vital and complex mental functions depends on adequate cerebrovascular perfusion pressure.[ww2.mc.vanderbilt.edu]
  • Morbidity is particularly high in the elderly, and is associated with loss of confidence, fear of falling, depression, fractures, and institutionalization. 2 Back to Top Physiology and Pathophysiology The pathophysiology of syncope involves the interaction[clevelandclinicmeded.com]
  • Hypertrophic Cardiomyopathy from A to Z: Genetics, Pathophysiology, Imaging, and Management. Radiographics 201636:335-54. Peritz DC, Howard A, Ciocca M, Chung EH.[acc.org]

Prevention

  • In conclusion, low levels of EPA and DHA are risk factors for cardiogenic syncope in patients with BrS, which suggests that n-3 PUFAs play important roles in preventing ventricular fibrillation in BrS.[ncbi.nlm.nih.gov]
  • Prevention of Syncope Trial (POST): a randomized, placebo-controlled study of metoprolol in the prevention of vasovagal syncope. Circulation. 2006;113:1164-1170. 26. Di Girolamo E, Di Iorio C, Sabatini P, et al.[uspharmacist.com]
  • It sounds like you already know a great deal about this, but I found this web page with some thoughts about helping prevent episodes: With afib, I manage the heck out of it by trying to avoid its triggers.[medhelp.org]
  • Usefulness of orthostatic self-training for the prevention of neurocardiogenic syncope. Pacing Clin Electrophysiol . 2002 ; 25 : 1454–1458.[circ.ahajournals.org]
  • References Occhetta E, Bortnik M, Audoglio R, Vassanelli C, INVASY Study InvestigatorsClosed loop stimulation in prevention of vasovagal syncope.[innovationsincrm.com]

References

Article

  1. Walsh K, Hoffmayer K, Hamdan MH. Syncope: diagnosis and management. Curr Probl Cardiol. 2015;40 (2):51-86
  2. Huff JS, Decker WW, Quinn JV, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with syncope. Ann Emerg Med. 2007;49(4):431-44.
  3. Atkins D, Hanusa B, Sefcik T, et al. Syncope and orthostatic hypotension. Am J Med. 1991;91(2):179-85.
  4. Calkins H, Shyr Y, Frumin H, et al. The value of the clinical history in the differentiation of syncope due to ventricular tachycardia, atrioventricular block, and neurocardiogenic syncope. Am J Med. 1995;98(4):365-73.
  5. Bergfeldt L. Differential diagnosis of cardiogenic syncope and seizure disorders. Heart 2003;89(3): 353-8.
  6. Reed MJ, Newby DE, Coull AJ, et al. The ROSE (risk stratification of syncope in the emergency department) study. J Am Coll Cardiol. 2010;23. 55(8):713-21.
  7. Rockx MA, Hoch JS, Klein GJ, et al. Is ambulatory monitoring for "community-acquired" syncope economically attractive? A cost-effectiveness analysis of a randomized trial of external loop recorders versus Holter monitoring. Am Heart J. 2005;150(5):1065.
  8. Dovgalyuk J, Holstege C, Mattu A, et al. The electrocardiogram in the patient with syncope. Am J Emerg Med. 2007;25(6):688-701.

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Last updated: 2018-06-22 04:01