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Evaluation and Management of Syncope

Syncope. Definition: Sudden transient loss of conciousness and postural tone with subsequent spontaneous recovery.. Syncope - Epidemiology. 1% of hospital admissions3% of ER visits6% annual incidence in the elderlyUpto 50% of young adults have history of isolated LOC Annual cost $800 M

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Evaluation and Management of Syncope

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    1. Evaluation and Management of Syncope

    2. Syncope Definition: Sudden transient loss of conciousness and postural tone with subsequent spontaneous recovery.

    3. Syncope - Epidemiology 1% of hospital admissions 3% of ER visits 6% annual incidence in the elderly Upto 50% of young adults have history of isolated LOC Annual cost $800 M (1999) Clin Electrophysiol 22:1386,1999

    4. Syncope - Prognosis Highest mortality in patients with cardiac cause Neurally mediated syncope/ medication induced syncope did not increase mortality Soteriades ES, et al: N Eng J Med 347:878, 2002

    5. Causes of Syncope Vascular ( 58 – 62 % ) : Reflex mediated, orthostatic, anatomic Cardiac ( 10 – 23 % ): Arrhythmias, anatomic Neurologic/cerebrovascular* ( 0.5 – 5 % ) Metabolic/drugs ( 0 – 2 % ) Psychogenic* ( 0.2 – 1.5 % ) Syncope of unknown origin ( 14 – 18 % )

    6. Differential Diagnosis of Syncope

    7. Syncope - Clinical Features Suggestive of Specific Causes

    8. Syncope – Clinical Features Suggestive of Specific Causes (cont’d )

    9. Syncope – Clinical Features Suggestive of Specific Causes ( cont’d )

    10. Diagnostic Tests for Syncope

    11. Diagnostic Tests for Syncope (cont’d)

    12. Sinus Arrest

    13. Syncope – Loop Event Recorder

    14. Implanted Loop Event Recorder

    15. Wide Complex Tachycardia – Loop Event Monitor

    16. Head Up Tilt Table Testing

    17. Neurally Mediated Syncope Also known as vasovagal syncope. Syncope in the absence of structural heart disease is most likely neurally mediated. Head-upright tilt test maximizes venous pooling, sympathetic activation and circulating catecholamines. Most vasovagal episodes involve both cardioinhibition (drop in heart rate) and vasodepressor response (drop in BP).

    19. Drugs Affecting Sinus Node Function Antiarrhythmic Drugs Amiodarone Flecainide, propafenone, sotalol Quinidine, disopyramide, procainamide Antihypertensives (Sympatholytic) Alpha-methyldopa, reserpine, clonidine Beta-Blockers Miscellaneous Cimetidine, Lithium, Phenytoin

    20. Sinus Node Recovery Time – 1 of 2

    21. Sinus Node Recovery Time – 2 of 2

    22. Electrophysiologic Recording of AV Block ( 1 of 2 )

    23. Electrophysiologic Recording of AV Block ( 2 of 2 )

    24. Therapy of Neurocardiogenic Syncope

    25. Syncope - Prognosis Highest mortality in patients with cardiac cause Neurally mediated syncope/ medication induced syncope did not increase mortality Soteriades ES, et al: N Eng J Med 347:878, 2002

    26. Suggested Strategies for Syncope Management

    27. Syncope: May be a harbinger of sudden cardiac death Evaluation – purpose is to determine if pt is at increased risk for death Identify pts with underlying heart disease (ischemic CM, non-ischemic CM, HCM), myocardial ischemia, WPW, genetic diseases (long-QT syndrome, Brugada Syndrome), catecholaminergic polymorphic VT

    28. AHA/ACCF Scientific Statement on the Evaluation of Syncope

    29. AHA/ACCF Scientific Statement on the Evaluation of Syncope, continued…

    30. Diagnostic Evaluation of Syncope

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