2. SYNCOPE
• ABRUPT, TRANSIENT, COMPLETE LOSS OF CONSIOUSNESS
ASSOCIATED WITH
• INABILITY TO MAINTAIN POSTURAL TONE
• WITH RAPID AND SPONTANEOUS RECOVERY
• OCCURS DUE TO CEREBRAL HYPOPERFUSION
3. HISTORY
• 1. DID THE PATIENT EXPERIENCE COMPLETE LOC?
• 2. WAS THE LOC TRANSIENT WITH A RAPID ONSET AND SHORT
DURATION?
• 3. DID THE PATIENT RECOVER SPONTANEOUSLY, COMPLETELY, AND
WITHOUT SEQUELAE?
• 4. DID THE PATIENT LOSE POSTURAL TONE?
• IF THE ANSWER TO ONE OR MORE OF THESE QUESTIONS IS
NEGATIVE, OTHER NON SYNCOPAL CAUSES OF TRANSIENT LOC
SHOULD BE SUSPECTED
4. HISTORY ABOUT THE SYNCOPAL ATTACK
• QUESTIONS ABOUT CIRCUMSTANCES JUST PRIOR TO THE ATTACK
• POSITION (SUPINE, SITTING or STANDING)
• ACTIVITY (REST, CHANGE IN POSTURE, DURING OR AFTER
EXERCISE, DURING OR IMMEDIATELY AFER URINATION,
DEFECATION, COUGH OR SWALLOWING)
• PRECIPITATING EVENTS (INTENSE PAIN, FEAR, NECK MOVEMENTS)
• PROLONGED STANDING
5. QUESTIONS ABOUT THE ATTACK
• PRIOR TO ATTACK:
• NAUSEA/ VOMITING, ABDOMINAL DISCOMFORT, FEELING OF COLD,
SWEATING, AURA, PAIN IN NECK OR SHOULDERS, BLURRED VISION
• PALPITATION
• END OF THE ATTACK:
• CONFUSION, INJURY, MUSCLE ACHES, SKIN COLOR, CHEST PAIN,
PALPITATION, URINARY OR FECAL INCONTINENCE
6. ABOUT THE ATTACK :(EYEWITNESS)
• WAY OF FALLING
• SKIN COLOR (PALLOR, CYANOSIS, FLUSHING)
• DUARTION OF LOC
• BREATHING PATTERN
• MOVEMNTS (TONIC, CLONIC, TONIC-CLONIC, AUTOMATISM,
MYOCLONIC JERKS)
• DURATION OF MOVEMENTS
• TONGUE BITING
7. BACKGROUND HISTORY
• H/O CARDIAC DISEASE OR METABOLIC DISEASE (DIABETES)
• FAMILY H/O CARDIAC DISEASE , SYNCOPE, OR SUDDEN DEATH
• NEUROLOGICAL HISTORY (PARKINSONISM, EPILEPSY, NARCOLEPSY)
• H/O DRUG INTAKE (ANTI HYPERTENSIVE, ANTI ANGINAL, ANTI
ARRYTHMIC, DIURETICS, QT PROLONGING DRUGS) & H/O ALCOHOL
INTAKE
• IDENTIFYING THE PRECIPITATING FACTORS INCLUDING BODY POSITION
AND ACTIVITY IMMEDIATELY BEFORE SYNCOPE
• DETAILED DESCRIPTION OF THE SYNCOPAL EPISODE
8. CLASSIFICATION OF SYNCOPE
• REFLEX (NEURALLY MEDIATED SYNCOPE)
• VASOVAGAL SYNCOPE
• SITUATIONAL SYNCOPE
• CAROTID SINUS SYNCOPE
• SYNCOPE DUE TO ORTHOSTATIC HYPOTENSION
• PRIMARY OR SECONDARY AUTONOMIC FAILURE, DRUG INDUCED OH,
VOLUME DEPLETION
• CARDIOVASCULAR SYNCOPE
• ARRHYTMOGENIC SYNCOPE
• SYNCOPE DUE TO STRUCTURAL HEART DISEASE
9.
10. NEURALLY MEDIATED SYNCOPE
• ABSENCE OF HEART DISEASE
• LONG HISTORY OF RECURRENT SYNCOPE
• NAUSEA / VOMITTING ASSOCIATED WITH SYNCOPE
• AFTER SUDDEN UNEXPECTED UNPLEASANT SIGHT, SMELL, SOUND OR PAIN
• DURING A MEAL OR POST PRANDIAL
• WITH HEAD ROTATION OR PRESSURE ON CAROTID SINUS (AS IN SHAVING,
TUMORS, TIGHT COLLARS)
• AFTER EXERTION
11. SYNCOPE DUE TO ORTHOSTATIC HYPOTENSION (OH)
• AFTER STANDING UP
• PROLONGED STANDING ESPCIALLY IN CROWDED , HOT PLACES
• PRENSENCE OF AUTONOMIC NEUROPATHY OR PARKINSONISM
• ASSOCIATED WITH START OF or INCREASE IN DOSAGE OF
VASODEPRESSIVE DRUGS
• STANDING AFTER EXERTION
12. CARDIOVASCULAR SYNCOPE
• PRESENCE OF DEFINITE STRUCTURAL HEART DISEASE
• FAMILY HISTORY OF SUDDEN UNEXPLAINED DEATH OR
CHANNELOPATHIES
• DURING EXERTION OR SUPINE
• SUDDEN ONSET PALPITATION FOLLOWED IMMEDIATELY BY SYNCOPE
• ECG FINDINGS SUGGESTIVE OF ARRYTHMOGENIC SYNCOPE
15. IDENTIFICATION OF HIGH RISK SYNCOPE PATIENTS
• SEVERE STRUCTURAL HEART DISEASE (LOW EF, PREVIOUS MI,
HEART FAILURE)
• CLINICAL FEATURES SUGGESTING ARRYTHMOGENIC SYNCOPE
• SYNCOPE DURING EXERTION OR WHILE SUPINE
• PALPITATIONS AT THE TIME OF SYNCOPE
• CLINICAL EVIDENCE OR SUSPICION OF A PULMONARY EMBOLUS
(SHORTNESS OF BREATH, SINUS TACHYCARDIA, CLINICAL SETTING)
• SEVERE ANAEMIA
• SIGNIFICANT ELECTROLYTE ABNORMALITIES
16. ECG FEATURES SUGGESTING ARRYTHMOGENIC
SYNCOPE
• NON SUSTAINED VT
• QRS > 120 ms;
• SEVERE SINUS BRADYCARDIA (HR< 50) IN THE ABSCENCE OF DRUGS /
PHYSICAL TRAINING
• PROLONGED OR VERY SHORT QT INTERVAL
• PRE EXCITATION
• BRUGADA ECG PATTERN (RBBB WITH STE IN V1 - V3)
• ARRYTHMOGENIC RIGHT VENTRICULAR DYSPLASIA ECG PATTERN
(T WAVE INVERSION IN LEADS V1 - V3 WITH OR WITHOUT EPSILON WAVES)
• ECG SUGGESTIVE OF HYPERTROPHIC CARDIOMYOPATHY