SYNCOPE: WHAT HAPPENS WHEN YOUR LIGHTS GO OUT ? Syed Raza MD,MRCP (UK),FCCP, Dip.Card (UK)
COMMON SCENARIO !
Collapse at home
No eye witness
Patient does not remember the event
Case Mrs L, 64yo F 66yo F , Mrs K, 59yo F Mrs M, 85yo F ? Seizure ? FA L L ? Orthostasis ? Neurocardiogenic
Diagnostic Work Up
Implications on driving
Syncope: A Symptom, Not a Diagnosis
Self-limited loss of consciousness and postural tone
Relatively rapid onset
Variable warning symptoms
Spontaneous, complete, and usually prompt recovery without medical or surgical intervention
Underlying mechanism: transient global cerebral hypoperfusion.
Impact of Syncope 1 Kenny RA, Kapoor WN. In: Benditt D, et al. eds. The Evaluation and Treatment of Syncope . Futura;2003:23-27. 2 Kapoor W. Medicine . 1990;69:160-175. 3 Brignole M, et al. Europace . 2003;5:293-298. 4 Blanc J-J, et al. Eur Heart J . 2002;23:815-820. 5 Campbell A, et al. Age and Ageing . 1981;10:264-270.
40% will experience syncope at least once in a lifetime 1
1-6% of hospital admissions 2
1% of emergency room visits per year 3,4
10% of falls by elderly are due to syncope 5
Major morbidity reported in 6% 1 eg, fractures, motor vehicle accidents
Minor injury in 29% 1 eg, lacerations, bruises
More than 1 billion pounds per year spent by NHS for managing falls and syncope.
Significant portion of the budget is spent on
clinical conditions which have been misdiagnosed ( i.e. 10% of syncope diagnosed as epilepsy)
Incidence Rates of Syncope According to Age and Sex Soteriades, E. et al. N Engl J Med 2002;347:878-885
Syncope with cardio inhibitory or mixed (cardio-inhibitory plus vasodepressor).
Severe brady cardia, AV or SA block
Over drive pacing for some tachy arrhythmia.
What are the indications for pacemaker therapy in neurocardiogenic syncope?
RCTs comparing vs
RCTs comparing vs
27 dual-chamber pacemakers
with rate-drop response
27 No pacemaker
The North American Vasovagal Pacemaker Study (VPS)
>6 lifetime episodes
+ tilt-table test
Primary outcome: first recurrence of syncope
Vascular, coronary, myocardial or conduction system disease
J. Am. Coll Cardiol . 1999;33:16-20 Pacemaker No pacemaker Recurrence of Syncope 6/27 (22%) 19/27 (70%) Time to recurrence 112 days 54 days
Soteriades E et al. N Engl J Med 2002;347:878-885 Overall Survival of Participants with Syncope, According to Cause, and Participants without Syncope
Driving Implications Group 1 Entitlement Group 2 Entitlement Simple faint –definite provocation with prodromal symptoms No driving restrictions No driving restrictions Unexplained syncope with low risk of recurrence Can drive 4 weeks after the event Can drive 3 months after the event Unexplained syncope & high risk of recurrence A abnormal ECG B structural heart disease C syncope at the wheel or results in injury D more than 1 episode in last 6 months Can drive 4 weeks after the event if cause identified and treated If no cause – 6 months off Can drive after 3 months if the cause identified and treated If no cause, licence revoked for year Loss of consciousness with no clinical pointers Full neuro/cardiac Ix with no pointers Licence revoked for 6 months Licence revoked for 1 year Cough syncope Stop driving until symptoms controlled Stop driving If smokes or respiratory disease have to be controlled for 5 years
Syncope is not an uncommon problem
The diagnosis of syncope is often missed or it is misdiagnosed
Thorough history from eye witness can be very helpful
Syncope can be fatal
Further training to identify the problem and formulating a plan of management is needed.