post graduate teaching seminar

1. 
 Chandan kr
SYNCOPE
syncope... 1
Dr CHANDAN KUMAR
VMMC&SAFDAJUNG,

2.  Self-limited loss of consciousness and postural
tone
 Relatively rapid onset
 Variable warning symptoms
 Spontaneous complete recovery
 Loss of consciousness occurs within 10
seconds of hypoperfusion of the reticular
activating system in the mid brain
syncope... 2

3. Causes of True Syncope
Orthostatic
Cardiac
Arrhythmia
Structural
Cardio-
Pulmonary
1
• VVS
• CSS
• Situational
Cough
Post-
Micturition
2
• Drug-Induced
• ANS Failure
Primary
Secondary
3
• Brady
SN
Dysfunction
AV Block
• Tachy
VT
SVT
• Long QT
Syndrome
4
• Acute
Myocardial
Ischemia
• Aortic
Stenosis
• HCM
• Pulmonary
Hypertension
• Aortic
Dissection
Neurally-
Mediated
66% 10% 11% 5% unexplained2%
Manual of cardiovascular medicine 4thed..griffin et al syncope... 3

4. Neurally-Mediated Syncope
 Absence of cardiac disease
 Long history of syncope
 After sudden unexpected, unpleasant sensation
 Prolonged standing in crowded, hot places
 Nausea vomiting associated with syncope
 During or after a meal
 With head rotation or pressure on carotid sinus
 After exertion
syncope... 4

5.  Vasovagal Syncope (VVS)
 Carotid Sinus Syndrome (CSS)
 Situational syncope
 Post-micturition
 Cough
 Swallow
 Defecation
 Blood drawing, etc.
syncope... 5

6. Neurally-mediated physiologic reflex mechanism
with two components:
1. Cardioinhibitory (↓ HR)
2. Vasodepressor (↓ BP) despite decrease in heart beats,
no significant BP generated
Both components are usually present
 Wieling W, Gert van Dijk J, van Lieshout J, Benditt D. Pathophysiology and
clinical presentation. In: Benditt D, Blanc J-J, et al. eds. The Evaluation and
Treatment of Syncope. Elmsford, NY: Futura. 2003;11-22.
syncope... 6

7. VVS
General Treatment Measures
• Optimal treatment
strategies for VVS are
a source of debate
• Treatment goals
– Acute intervention
• Physical maneuvers,
eg,
crossing legs or
tugging arms
• Lowering head
• Lying down
• Long-term
prevention
– Tilt training
– Education
– Diet, fluids, salt
– Support hose
– Drug therapy
– Pacing
•Drug therapy should be used as a second line option. Midodrine and beta-
adrenergic blockers are the agents most thoroughly studied to date
syncope... 7

8. CSS
Carotid Sinus Syndrome
• Syncope clearly associated with carotid sinus
stimulation is rare (≤1% of syncope)
• CSS may be an important cause of
unexplained syncope/falls in older
individuals
• Prevalence higher than previously believed
• Carotid Sinus Hypersensitivity (CSH)
syncope... 8

9.  Sensory nerve endings in the carotid
sinus walls respond to deformation
 Previous neck surgery may contribute
 Increased afferent signals to brain stem
 Reflex increase in efferent vagal activity and
diminution of sympathetic tone results in
bradycardia and vasodilatation
syncope... 9

10. Carotid Sinus Massage (CSM)
• Method
– Massage, 5-10
seconds
– Don’t occlude
– Supine and upright
posture
(on tilt table)
• Outcome
– 3 second asystole
and/or 50 mmHg
fall in systolic BP
with reproduction of
symptoms = Carotid
Sinus Syndrome
• Absolute
contraindications
– Carotid bruit,
known significant
carotid arterial
disease, previous
CVA, MI last 3
months
• Complications
– Primarily
neurological
– Less than 0.2%
syncope... 10

11. SAFE PACE
Syncope And Falls in the Elderly – Pacing And Carotid
Sinus Evaluation
• Objective
– Determine whether
cardiac pacing
reduces falls in
older adults with
carotid sinus
hypersensitivity
• Randomized controlled
trial (N=175)
– Adults > 50 years,
non-accidental fall,
positive CSM
– Pacing (n=87) vs.
No Pacing (n=88)
• Results
– More than 1/3 of
adults over 50 years
presented to the
Emergency
Department
because of a falls
have CS
hypersensitivity
– With pacing, falls 
70%
– Syncopal events Kenny RA. J Am Coll Cardiol. 2001;38:1491-1496. syncope... 11

12. Syncope due to orthostatic hypotension
 After standing up
 Temporal relationship to taking a medication
that can cause hypotension
 Prolonged standing
 Presence of autonomic neuropathy
 After exertion
syncope... 12

13. Orthostatic Hypotension
• Etiology
• Drug-induced (very common)
– Nitrates,ACE
inhibitors,CCB,diuretics.
alpha blockers,
• Primary autonomic failure
Multiple system atrophy
– Parkinson’s Disease
– Dementia with lewy
body
– Postural Orthostatic
Tachycardia Syndrome
(POTS)
• Familial dysautonomia
(Riley day syndrome-
• Hereditary sensory and
autonomic neuropathy-
AR inheritance-
hperhidrosis,labileBP,pain
insensitivity etc
syncope... 13

14.  Secondary autonomic failure
 Diabetes
 Alcohol
 Amyloid
 SPINAL TUMOURS
syncope... 14

15.  Upright posture results in translocation of 30%
of central blood volume to dependent body
parts within seconds and transcapillary fluid
shifts over 30 minutes further reduce blood
volume by 5%.
 Compensatory responses
Muscle pump
Nuerovascular compensation
Humoral compensation
Local vascular
syncope... 15

16.  autonomic disturbance characterised by the clinical
symptoms of orthostatic intolerance, mainly
light‐headedness, fatigue, sweating, tremor, anxiety,
palpitation, exercise intolerance and near syncope on
upright posture.
 Increase in heart rate to >120 beats/minute or an
increase of 30 beats/min with standind that subsides
on lying down.
 Male :female=5:1
 Age-15 to 50 years
 Pathogenesis unclear.beta receptor
insessitivity,impaired brain stem regulation
syncope... 16

17.  TREATMENT
 Expansion of fluid volume
 Postural training
 Midodrine,fludrocortisone –tried with
some success.
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21. syncope... 21

22.  Patient education, injury avoidance
 Hydration
 Fluids, salt, diet
 Minimize caffeine/alcohol.
 Sleeping with head of bed elevated
 Tilt training, leg crossing, arm pull
 Support hose
 Drug therapies
 Fludrocortisone, midodrine, erythropoietin.
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23. syncope... 23

24. Cardiac Syncope
 Presence of structural heart disease
 With exertion or supine
 Preceded by palpitations
 Family history of sudden death
syncope... 24

25.  Bradycardia/asystole
 Sick sinus syndrome
 2nd or 3rd degree AV blocks
 Pacemaker malfunction
 Have high suspicion in patients with bundle
blocks…
 Tachycardia
 Ventricular tachycardia
 Ventricular fibrillation
 SVT
 Long QT syndrome
syncope... 25

26.  Valvular disease (especially aortic stenosis)
 HOCM
 Cardiac masses (myxoma)
 Pericardial disease (tamponade or restrictive
processes)
 Prosthetic valve dysfunction
 Acute aortic dissection
 Pulmonary hypertension (exercise related)
 PE
syncope... 26

27. San Francisco Syncope Rules
To Guide Inpatient Admission
1. C – (History of Congestive heart failure)
2. H – (Hematocrit < 30%)
3. E – Abnormal ECG
4. S – Shortness of breath
5. S – SBP < 90
 1st validation study: 96% sensitive, 62%
specific for predicting serious outcome at 7
days
 2nd validation study: not as good
 Main point: “further validation is needed
before can be widely applied…[but]syncope... 27

28. Triad
1.RBBB pattern in right precordial leads
2.Transient/persistent ST elevation in v1-v3
3.Sudden cardiac death
Structurally normal heart
Pathogenesis-Na channel abnormality
Association with young and healthy men from southeast
asia who present with sudden cardiac death
Brugada sign may be asymptomatic
High risk of sudden cardiac death in those who have
syncope or family history of sudden death (Indication for
AICD based upon observational data)
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29. syncope... 29

30.  TREATMENT-
 Quinidine
 ICD
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31. syncope... 31

32. syncope... 32
JCE 1999;10:1664-1683

33.  3 main factors contributing to syncope
or SCD
 Exercise (LQT1), especially swimming
 Emotions or emotional stress (LQT2)
 Events occurring during sleep or at rest,
with or without arousal (LQT2 or LQT3)
syncope... 33

34.  Long QT1-most common. Chromosome
11p15.5 (LQT1),
 Exercise precipitates
 Two LQ1 alleles-Jervell and Lange –Nielson
syndrome ---- marked QT prolongation
associated with deafness…..worse prognosis
 T wave is broad
 Long QT2- Chromosome 7q35-36 (LQT2),T
wave notched and bifid-precipitated by
emotional stress,sleep or auditory stimulation
syncope... 34

35.  Long QT3-sodium channel defect- chromosome
3p21-24 (LQT3).
 Twave –late onset biphasic T wave or asymmetric
peaked T wave.
 Male predominance
 Most events occur during sleep
 worst prognosis of all QTs.
 Treatment-
 a.ICD implantation
 Beta blocker are also effective
 Avoidance of drugs that prolong QT interval
syncope... 35

36. syncope... 36
Moss AJ, et al. Circulation 1995;92:2929-2934

37.  In current practice ECG monitoring is usually
undertaken with conventional 24–48 h, or even
7 day, Holter recorders
 Daily single or multiple episodes of LOC might
increase the potential for symptom–ECG
correlation.
 the true yield of Holter in syncope may be as
low as 1–2% in an unselected population.
syncope... 37

38.  loop memory that continuously records and
deletes ECG
 connected to the patient through cutaneous
patch electrodes.
 When activated by the patient, typically after a
symptom has occurred, 5–15 min of pre-
activation ECG is stored and can be retrieved
for analysis.
syncope... 38

39. The ILR is an implantable patient – and
automatically – activated monitoring system
that records subcutaneous ECG.
-battery life of up to 36 months.
syncope... 39

40. Patient Activator Reveal®
Plus ILR 9790 Programmer
Reveal
®
Plus
Insertable Loop Recorder
syncope... 40

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44. syncope... 44

45.  an invasive procedure that evaluated
abnormal heart rhythm disturbances.
syncope... 45

46. syncope... 46

47. 1. rapid (,2 s) injection of a 20 mg bolus of ATP
(or adenosine) during ECG monitoring.
2. The induction of AV block with ventricular
asystole lasting .6 s, or the induction of AV block
lasting .10 s, are considered abnormal.
3. ATP testing produced an abnormal response in
some patients with syncope of unknown origin .
4.paroxysmal AV block could be the cause of
unexplained syncope.
syncope... 47

48.  Seems to identify a unique mechanism of syncope found
in patients with:
 Advanced age
 More hypertension
 More ECG abnormalities
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53. syncope... 53

54.  Migraine*
 Acute hypoxemia*
 Hyperventilation*
 Somatization disorder (psychogenic syncope)
 Acute Intoxication (e.g., alcohol)
 Seizures
 Hypoglycemia
syncope... 54

55. Disorders without impairment of consciousness
Cataplexy
Psychogenic pseudo-syncope
Disorders with loss of consciousness
Metabolic disorders
Epilepsy
Intoxications
Vertebrobasilar transient ischemic attacks
syncope... 55

56.  Proximal subclavian artery stenosis
 Decreased blood flow to distal subclavian artery
worsened with exertion of arm
 Blood from vertebral artery on opposite side goes
to basilar artery and then down ipsilateral
vertebral artery, away from brainstem, to serve as
collateral for arm
 Usually asymptomatic
 Atherosclerosis
 Symptoms of vertebrobasilar insufficiency
(dizziness, vertigo, diplopia, nystagmus)
 Rare to have permanent neurological deficits
 Diagnosis with dopplers, MRA
 Treatment: surgical revascularization, stents
syncope... 56

57. syncope... 57
Conventional Diagnostic Methods/Yield
* Structural Heart Disease
†
1 Kapoor, et al N Eng J Med, 1983.
2 Kapoor, Am J Med, 1991.
3 Linzer, et al. Ann Int. Med, 1997.
4 Kapoor, Medicine, 1990.
5 Kapoor, JAMA, 1992
6 Krahn, Circulation, 1995
7 Krahn, Cardiology Clinics, 1997.
8 Eagle K,, et al. The Yale J Biol and Medicine. 1983; 56: 1-8.
9 Day S, et al. Am J Med. 1982; 73: 15-23.
10 Stetson P, et al. PACE. 1999; 22 (part II): 782.

58. The only difference between
syncope and sudden death
is that in one you wake
up………THANKU.

59.  The efficacy of beta-blockers in these patients
may be due to blunting of elevated
catecholamine levels that precede vasovagal
syncope
 Journal of the American College of Cardiology
 Vol. 51, No. 24, 2008
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60. syncope... 60