Syncope

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Syncope or Near Syncope

• Differential Diagnosis and Cost Effective Workup

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Syncope

• Common reason to present to ER or to ambulatory
  clinic
• Transient loss of consciousness that is
  accompanied by loss of postural tone
• Due to transient hypoperfusion of the brain (from
  numerous causes)
• Near syncope?similar workup
• Rarely necessitates hospital admission
• Etiology broadly divided into three categories
• head, heart, and vessels

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Head

• Primary neurologic events seizures (atonic
  seizures, temporal lobe seizures, unwitnessed
  grand mal seizures)
• Psychiatric illness anxiety, panic attack,
  conversion disorder
• Neurally mediated events reflex mechanisms that
  are associated with inappropriate vasodilatation,
  bradycardia, or both.
• --includes vasovagal, vasodepressor,
  situational, carotid sinus syndrome

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Heart

• Cardiac related events that cause a sudden drop
  in cardiac output and therefore syncope
• --tachyarrthymia (SVT, VT, torsades with long
  QT)
• --bradyarrythmias
• --PE (sizable)
• --atrial myxoma
• --ischemia
• --inability to increase cardiac output with
  activity IHSS, aortic stenosis

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Vessels (Orthostatic Hypotension)

• Medication related (antihypertensives, others)
• Autonomic insufficiency
• Dehydration/volume depletion
• Exaggerated physiologic response (hot tub
  syncope, esp after EtOH)
• Rare disordersAddisons, panhypopit, Shy-Drager

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Workup Take home points

• Shot gun approach not helpful
• Patients remain undiagnosed in 34 of cases
• Most common to least common diagnosis
  vasovagal, cardiac arrhythmia, orthostatic
  hypotension, seizure
• Therefore, directed (and thorough) history and
  physical and an EKG can pinpoint the problem in
  most cases

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History

• What exactly was the patient doing (positional,
  exertional, situational)
• Any prodrome
• Postictal symptoms
• Medication history
• Interview family or witnesses

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PE

• Check Orthostatic BP
• Cardiac exammurmur of AS/IHSS, tumor plop,
  pulmonary HTN with RVH
• Thorough neurologic exam
• EKG look for old infarcts, BBB, AV block

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What about other tests?

• Labs rarely useful electrolytes may reveal low
  K/Mg/Na/Ca, renal failure, or
  hypo/hyperglycemia
• These are rare to cause an event in and of
  themselves, but can point to other etiology
  (seizure)
• Head CT, EEG only if focal neurologic findings
  or if prior history of seizure
• Carotid dopplers appropriate in the presence of
  bruits or when the history suggests VBI

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What if initial evaluation is negative?

• First, reassure patient (recall that a third
  remain undiagnosed prognosis is generally good)
• If suspected heart disease or risk factors for
  heart disease echo, exercise stress test,
  Holter monitor
• Elderly patients same as above but consider
  polypharmacy, situational syncope
• Younger patients not known or suspected to have
  heart disease ambulatory loop ECG, tilt table
  testing, and psychiatric evaluation for
  anxiety/panic disorder