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Syncope diagnostic algorithm and management

Syncope diagnostic algorithm and management. MUDr. Jakub Honěk Kardiologická klinika, 2.LF UK a FN Motol, Praha. Definition of syncope. Syncope is a T-LOC due to transient global cerebral hypoperfusion characterized by rapid onset, short duration, and spontaneous complete recovery.

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Syncope diagnostic algorithm and management

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  1. Syncopediagnostic algorithm and management MUDr. Jakub Honěk Kardiologická klinika, 2.LF UK a FN Motol, Praha

  2. Definition of syncope • Syncope is a T-LOC due to transient global cerebral hypoperfusioncharacterized by rapid onset, short duration, and spontaneouscomplete recovery. • T-LOC – all cases of transient loss of consciousness regardless of the pathophysiological mechanism Transient loss of consciousness Global cerebral hypoperfusion = circulatory cause Rapid onset Short duration Spontaneous complete recovery ESC Guidelines for the diagnosis and management of syncope (version 2009): Moya et al. Eur Heart J, 2009.

  3. Significance, epidemiology • Risk of fall and trauma • A warning signal of sudden death • Mostly benign in young • A common complaint – 3% of emergency visits • A fraction of patients see a doctor • Bimodal age distribution

  4. Prognosis, significance of syncope management and diagnostics Soteriades et al. N Eng J Med, 2003.

  5. Classification of syncope

  6. Initial diagnostic work-up • A thorough history • What preceded syncope, prodromes, eyewitness report, symptoms after syncope • Personal and family history, medication, recurrent syncope? • Physical exam • BP supine and standing • 5 min. supine, 1st and 3rd min. standing • ECG

  7. Initial evaluation – key questions

  8. Initial evaluation

  9. Initial evaluationRisk startification • Structural heart disease • CHD (previous MI), heart failure, aortic stenosis, HCM… • Clinical or ECG signs suggestive of arrhytmic etiology • Syncope while supine, exercising, palpitations • Family history of sudden death • Bifascicular block, nsVT, susp. SSS, preexcitation, ↑QTc, Brugada, susp. ARVC • Age >40 + recurrent syncope (50% arrhythmia) • Severe comorbidities • Anemia, ion dysbalance

  10. Further evaluationDiagnostic methods • Carotidmassage • Pause > 3s, BP drop > 50 mmHg • Unknown cause in pts. > 40 yrs • Tilttest • Reflex syncope - cardioinhibitory, vasodepresoric and mixedreaction X ortostatichypotension • Indicated in suspected reflex syncope, unknown etiology, susp. OH, difdg. offalls, pseudosyncope…

  11. Further evaluationDiagnostic methods • ECG monitoring • In-hospital monitoring • High-risk pts. • Holter ECG (24h, 48h, 7d) • frequent syncope/presyncope • Implantable/external loop recorder (ILR) • Recurrent syncope of unknown etiology, therapy-resistant epilepsy, susp. arrhytmic cause • Arrhythmia during syncope or occurrence of severe arrhythmia make diagnosis, syncope with no ECG changes rule out arrhythmic cause

  12. Further evaluationDiagnostic methods • Electrophysiological exam • Specific indications, high suspicion not confirmed non-invasively • Echocardiography • Risk stratification, structural heart disease • Stress test • Psychiatric evaluation • Neurological evaluation

  13. Take home messages • Not every LOC is a syncope • Thorough history is the cornerstone • Initial evaluation makes diagnosis 25-40%, risk-stratification in the rest • There is plenty of diagnostic methos, use them wisely

  14. TherapyIndications for permanent pacing • SSS + ECG correlatedsymptoms • SSS + abnormal CSNRT • Asymptomaticpauses>6s (SSS/AVB) • AVB II Mobitz II, AVB III • BBB + abnormal HV conduction • Alternating BBB • BBB + unexplainedsyncope – risk/ILR • Reflex cardio-inhibitory – „ultimum refugium“ • Syncopedue to hypersensitivecarotid sinus

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