Syncope

64 Syncope



James Quinn



image      Key Points




• Syncope is a symptom, not a diagnosis.


• Patients with cardiac syncope have a 6-month mortality rate in excess of 10%.


• If the diagnosis can be made, the disposition will be based on that diagnosis.


• When the patient’s symptoms have resolved and the cause is unclear, risk stratification can help in making decisions on disposition.


• Risk factors in emergency department patients include abnormal electrocardiographic findings, including any rhythm abnormalities detected during monitoring. Other risk factors include a history of cardiac disease (especially congestive heart failure) and absence of a prodrome, which places patients at risk for unfavorable cardiac outcomes. Those with persistently abnormal vital signs, shortness of breath, or a low hematocrit are also at higher risk for other adverse outcomes.



Epidemiology


It is estimated that 1 in 4 people will faint during their lifetime and that 6 in 1000 people per year will suffer from the symptom of syncope. Syncope is responsible for 1% to 2% of all emergency department (ED) visits, and the cost of hospitalization for syncope approaches $2 billion annually.1–4


Syncope is defined as a transient loss of consciousness that does not require resuscitative efforts and subsequent return to the patient’s baseline neurologic condition. Loss of consciousness associated with neurologic deficits or persistent alteration in the level of consciousness is, strictly speaking, not properly described as syncope; although such events are commonly referred to as syncope in the literature, in this chapter they are termed apparent syncope.



Pathophysiology


Syncope comes from the Greek word synkoptein, meaning “to cut short.” Hippocrates was the first to use the term and describe the symptom.5 Syncope has many causes, but the pathophysiology of the final pathway is the same: hypoperfusion of the cerebral cortex and reticular activating system, which after 8 to 10 seconds of interrupted perfusion causes loss of consciousness; a shorter period results in lightheadedness or dizziness and is referred to as near syncope.



Presenting Signs and Symptoms


The symptoms of syncope can be dramatic. Patients may or may not have a warning, or prodrome, and frequently suffer a fall and have associated trauma. Those with a prodrome frequently experience lightheadedness, diaphoretic warmth, nausea and vomiting, or any combination of these symptoms. Those witnessing the event often fear that the patient has died or was dead for a short period, thus making it an emotionally charged and anxiety-provoking event.



Classification of Syncope


The American College of Physicians lists four major prognostic categories of syncope: neurally mediated, orthostatic, neurogenic, and cardiac; actually, a fifth category (“syncope of unknown cause”) is recognized because in most cases the cause of the syncope remains unknown even after extensive investigation.6,7



Neurally Mediated Syncope


Neurally mediated syncope is syncope associated with inappropriate vasodilation, bradycardia, or both as a result of inappropriate vagal or sympathetic tone.8 It is a benign type of cardiovascular syncope that is often associated with a sensation of increased warmth and may be accompanied by preceding lightheadedness (prodrome) along with sweating and nausea. A slow, progressive onset suggests the subcategory vasovagal syncope. Sweating and nausea do not occur with orthostatic hypotension, which is another cause of syncope preceded by lightheadedness.5


Neurally mediated or vasovagal syncope may occur after exposure to an unexpected or unpleasant sight, sound, or smell; fear or other emotional distress; severe pain; or surgical procedure. It may also occur in association with prolonged standing or kneeling in a crowded or warm place or after exertion. As a result, the vagus nerve is stimulated, which causes reflex bradycardia and vasodilation.


Situational syncope occurs during or immediately after coughing, micturition, defecation, or swallowing via a similar mechanism. Carotid sinus syncope can be associated with neck pressure (shaving, tight collar) or head turning resulting in stimulation of the carotid sinus in the neck.



Orthostatic Syncope


Orthostatic syncope occurs in individuals with documented postural hypotension associated with syncope or symptoms of presyncope.4 In cases of orthostatic syncope, measurement of blood pressure is recommended, first after the patient is supine for 5 minutes and then after the patient is able to stand for 1 to 3 minutes. A decrease of more than 20 mm Hg in systolic pressure is considered abnormal, as is a drop in pressure below 90 mm Hg independent of the development of symptoms.9


Because orthostatic hypotension occurs in asymptomatic individuals, vital signs are neither particularly sensitive nor specific. In fact, positive orthostatic changes have been documented in up to 40% of asymptomatic patients older than 70 years and in 25% of those younger than 60 years. Similarly, a notable number of children who are asymptomatic have been documented to have orthostatic hypotension.5,10


The most common cause of orthostatic syncope is intravascular volume loss, which may be due to dehydration or bleeding. Orthostatic syncope is not always benign because many patients with serious causes can have this symptom.11



Neurologic Syncope


Neurologic causes of apparent syncope include seizures, transient ischemic attacks, migraine headaches, subarachnoid hemorrhage, and subclavian steal syndrome. Confusion after apparent syncope that lasts more than 5 minutes, tongue biting, incontinence, and epileptic aura suggest a seizure. A significant differential in blood pressure between the two arms suggests subclavian steal or dissection. For neurologic causes to be considered true syncope, they must by definition be transient in nature and result in a return to baseline neurologic function. Thus, loss of consciousness with persistent neurologic deficits or altered mental status is not true syncope. In fact, according to this criterion very few neurologic events (especially strokes or subarachnoid hemorrhage) meet the definition of syncope.


Most cases involving neurologic causes of syncope are easily predicted. In general, when these patients have symptoms suggesting a specific disease process, the need for intervention based on neurologic symptoms is usually obvious. It is not recommended that a routine neurologic work-up be performed in all patients with syncope unless related neurologic symptoms are present. It has been determined that routine neurologic testing and investigation, such as computed tomography (CT), is not cost-effective in patients without neurologic symptoms.12



Cardiac-Related Syncope


Cardiac-related syncope is clearly the most dangerous class of syncope, and it can be a harbinger of sudden death. Because patients with documented cardiac syncope have a 6-month mortality rate of greater than 10%, timely and thorough evaluation is warranted.13


Syncope in this class can be caused by many types of arrhythmias (benign and malignant), valvular and ischemic heart disease, and cardiomyopathies. Although it is clear that patients with known cardiac disease and syncope have a significantly increased incidence of cardiac-related death, cardiac disease may not be recognized in many patients with cardiac syncope, and persons with a history of cardiac disease may appear to be very stable. Therefore, depending on the history and age of the patient, a relatively aggressive search for cardiac problems may be necessary. However, the urgency of these investigations and whether they should be done in the ambulatory or inpatient setting (e.g., monitoring) are unclear.



Syncope of Unknown Cause


Syncope of unknown cause is the largest category of syncope, with estimates as high as 40%, even with extensive work-up.1 Some studies have found that after evaluation in the ED, physicians are uncertain of the cause of the syncope more than 50% of the time.14

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Jun 14, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Syncope

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