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SYNCOPE: WHAT HAPPENS WHEN YOUR LIGHTS GO OUT  ? Syed Raza MD,MRCP (UK),FCCP, Dip.Card (UK)
COMMON SCENARIO ! ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Case    Mrs L, 64yo F                 66yo F         ,        Mrs K,  59yo F               Mrs M,  85yo F           ? Seizure ?  FA L L ? Orthostasis ? Neurocardiogenic
 
 
 
 
 
 
 
 
Objectives ,[object Object],[object Object],[object Object],[object Object],[object Object]
Syncope: A Symptom, Not a Diagnosis ,[object Object],[object Object],[object Object],[object Object],[object Object],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. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
THE  COST ,[object Object],[object Object],[object Object]
Incidence Rates of Syncope According to Age and Sex Soteriades, E. et al. N Engl J Med 2002;347:878-885
 
Classification Syncope Neurally Mediated 34% Vasovagal Carotid Sinus Situational Glossopharyngeal Neuralgia Cerebrovascular Autonomic Failure Cardiac Mediated 18% Arrythmia Srtructural Heart Disease Cardiopulmonary Disease Others 47% Orthostatic Hypotension Idiopathic Medications Psychiatric
Causes of syncope*   ,[object Object],[object Object],[object Object],[object Object],[object Object],*  Data pooled from 4 population studies n=1640 patients
Neurally Mediated Syncope ,[object Object],[object Object],[object Object],[object Object]
Neurally Mediated Syncope (autonomic failure) ,[object Object],[object Object]
Neuro-Cardiogenic Syncope ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Pathophysiology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Carotid Sinus Syndrome ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Carotid Sinus Syncope and Autonomic Dysfunction Freeman, M.  Neurogenic Orthostatic Hypotension.  NEJM 2008; 358: 616
 
POSTURAL  BP
 
Postural Blood Pressure ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Orthostatic Hypotension ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
POSTURAL ORTHOSTATIC TACHYCARDIA  SYNDROME  (POTS) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Initial evaluation: History ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Diagnostic tests ,[object Object],[object Object],[object Object]
Carotid Sinus Massage Protocol ,[object Object],[object Object],[object Object],[object Object]
Carotid Sinus Massage ,[object Object],[object Object],[object Object],[object Object]
Positive CSM Test ,[object Object],[object Object],[object Object]
TILT TABLE TEST
Tilt Table Test In Action
Indications for Tilt Table Testing ,[object Object],[object Object],[object Object],[object Object]
Upright Tilt Table Test ,[object Object],[object Object]
Tilt Table Testing ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Normal test
Cardioinhibitory response
Vasodepressor response BP drops from 150/70 to 50/30 but heart rate stays same
Mixed response BP drops from 150/60 to 50/20 while HR drops from 65 to 30bpm
 
Orthostatic hypotension steady drop in BP and rise in HR
Heart Monitoring Options Syncope Occurs Infrequently,  Long-term Monitoring is Likely to be Most Effective ILR MCOT External Loop Recorder Typical Event Recorder Holter Monitor 12-Lead 2 Days 7 Days 30+ Days 36 Months 10 Seconds ILR = insertable loop recorder MCOT= mobile cardiac outpatient telemetry
 
Everything is spinning
MANAGEMENT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Postural hypotension ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Pharmacological  therapy ,[object Object],[object Object],[object Object],[object Object],[object Object]
Management of Neurally Mediated Syncope Grubb BP.  NEJM.  2005.  352(10): 1004-1010
INDICATION  FOR  PACEMAKER  ,[object Object],[object Object],[object Object]
What are the indications for pacemaker therapy in neurocardiogenic syncope? ,[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],The North American Vasovagal Pacemaker Study (VPS) ,[object Object],[object Object],[object Object],[object Object],Primary outcome: first recurrence of syncope ,[object Object],[object Object],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
SUMMARY ,[object Object],[object Object],[object Object],[object Object],[object Object]
 
ANY  QUESTION ??
 

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Syncope

  • 1. SYNCOPE: WHAT HAPPENS WHEN YOUR LIGHTS GO OUT ? Syed Raza MD,MRCP (UK),FCCP, Dip.Card (UK)
  • 2.
  • 3. Case Mrs L, 64yo F 66yo F , Mrs K, 59yo F Mrs M, 85yo F ? Seizure ? FA L L ? Orthostasis ? Neurocardiogenic
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  • 16. Incidence Rates of Syncope According to Age and Sex Soteriades, E. et al. N Engl J Med 2002;347:878-885
  • 17.  
  • 18. Classification Syncope Neurally Mediated 34% Vasovagal Carotid Sinus Situational Glossopharyngeal Neuralgia Cerebrovascular Autonomic Failure Cardiac Mediated 18% Arrythmia Srtructural Heart Disease Cardiopulmonary Disease Others 47% Orthostatic Hypotension Idiopathic Medications Psychiatric
  • 19.
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  • 25. Carotid Sinus Syncope and Autonomic Dysfunction Freeman, M. Neurogenic Orthostatic Hypotension. NEJM 2008; 358: 616
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  • 38. Tilt Table Test In Action
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  • 44. Vasodepressor response BP drops from 150/70 to 50/30 but heart rate stays same
  • 45. Mixed response BP drops from 150/60 to 50/20 while HR drops from 65 to 30bpm
  • 46.  
  • 47. Orthostatic hypotension steady drop in BP and rise in HR
  • 48. Heart Monitoring Options Syncope Occurs Infrequently, Long-term Monitoring is Likely to be Most Effective ILR MCOT External Loop Recorder Typical Event Recorder Holter Monitor 12-Lead 2 Days 7 Days 30+ Days 36 Months 10 Seconds ILR = insertable loop recorder MCOT= mobile cardiac outpatient telemetry
  • 49.  
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  • 54. Management of Neurally Mediated Syncope Grubb BP. NEJM. 2005. 352(10): 1004-1010
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  • 58. 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
  • 59. 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
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Editor's Notes

  1. 1 Kenny RA, Kapoor WN. Epidemiology and social costs. In: Benditt D, Blanc J-J, et al. eds. The Evaluation and Treatment of Syncope . Elmsford, NY: Futura;2003:23-27. 2 Kapoor W. Evaluation and outcome of patients with syncope. Medicine . 1990;69:160-175. 3 Brignole M, Disertori M, Menozzi C, et al. Management of syncope referred urgently to general hospitals with and without syncope units. Europace . 2003;5:293-298. 4 Blanc J-J, L’ Her C, Touiza A, et al. Prospective evaluation and outcome of patients admitted for syncope over a 1 year period. Eur Heart J . 2002;23:815-820. 5 Campbell A, Reinken J, Allan B, et al. Falls in old age: A study of frequency and related clinical factors. Age and Ageing . 1981;10:264-270.
  2. There is severe impairment of neurocardiovascular reflex which leeds to pooling of a significant of blood in the leg vessels.
  3. Stimulation of baro receptors in the carotid body would send neuronal signals to NTS in the brain stem via glossopharyngeal nerve.This inturn would lead to increased parasympathetic nervous tone, inhibiting SA and AV node causing bradycardia.There is also sympathetic withdrawl leading to vasodilataion and hypotension.
  4. Common in elderly and they are most vulnerable due to .. Decreased baro receptor …
  5. Also known as POTS is seen in younger women who usually present dizzyness or faint on sudden standing.
  6. Figure 2. Overall Survival of Participants with Syncope, According to Cause, and Participants without Syncope. P<0.001 for the comparison between participants with and those without syncope. The category "Vasovagal and other causes" includes vasovagal, orthostatic, medication-induced, and other, infrequent causes of syncope.