SYNCOPE in Objective-C

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ESSENTIALS OF DIAGNOSIS
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Transient loss of consciousness and postural tone due to inadequate cerebral blood flow and oxygen delivery from vasomotor or cardiogenic causes
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Carotid sinus massage in patients who do not have carotid bruits or a history of cerebral vascular disease can precipitate sinus node arrest or AV block in patients with carotid sinus hypersensitivity Head-up tilt-table testing can identify patients whose syncope may be on a vasovagal basis Although different testing protocols are used, passive tilting to at least 70 degrees for 10 40 minutes in conjunction with isoproterenol infusion, if necessary is typical Syncope due to bradycardia, hypotension, or both will occur in approximately one-third of patients with recurrent syncope Some studies have suggested that, at least with some of the more extreme protocols, false-positive responses may occur 3 Electrophysiologic studies Electrophysiologic studies to assess sinus node function and AV conduction and to induce supraventricular or ventricular tachycardia are indicated in patients with recurrent episodes, nondiagnostic ambulatory ECGs, and negative autonomic testing if vasomotor syncope is a consideration Electrophysiologic studies reveal an arrhythmic cause in 20 50% of patients, depending on the study criteria, and are most often diagnostic when the patient has had multiple episodes and has identifiable cardiac abnormalities 4 Exercise testing When the symptoms are associated with exertion or stress, exercise testing may be helpful
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tachycardia), pulmonary stenosis, hypertrophic obstructive cardiomyopathy, congenital lesions associated with pulmonary hypertension or right-to-left shunting, and LA myxoma obstructing the mitral valve Episodes are commonly exertional or postexertional More commonly, cardiac syncope is due to disorders of automaticity (sick sinus syndrome), conduction disorders (AV block), or tachyarrhythmias (especially ventricular tachycardia and supraventricular tachycardia with rapid ventricular rate)
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Clinical Findings
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A Symptoms and Signs
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Syncope is characteristically abrupt in onset, often resulting in injury, transient (lasting for seconds to a few minutes), and followed by prompt recovery of full consciousness Vasomotor premonitory symptoms, such as nausea, diaphoresis, tachycardia, and pallor, are usual in the common faint Episodes can be aborted by lying down or removing the inciting stimulus In orthostatic (postural) hypotension, a greater than normal decline (20 mm Hg) in blood pressure immediately upon arising from the supine to the standing position is observed, with or without tachycardia depending on the status of autonomic (baroreceptor) function
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B Diagnostic Tests
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The evaluation for syncope depends on findings from the history and physical examination (especially orthostatic blood pressure evaluation, examination of carotid and other arteries, cardiac examination and, if appropriate, carotid sinus massage) 1 ECG The resting ECG may reveal arrhythmias, evidence of accessory pathways, prolonged QT interval, and other signs of heart disease (such as infarction or hypertrophy) If the history is consistent with syncope, ambulatory ECG monitoring is essential This may need to be repeated several times, since yields increase with longer periods of monitoring, at least up to 3 days Event recorder and transtelephone ECG monitoring may be helpful in patients with intermittent presyncopal episodes Caution is required before attributing a patient s symptom to rhythm or conduction abnormalities observed during monitoring without concomitant symptoms In many cases, the symptoms are due to a different arrhythmia or to noncardiac causes For instance, dizziness or syncope in older patients may be unrelated to concomitantly observed bradycardia, sinus node abnormalities, and ventricular ectopy 2 Autonomic testing Studying patients with a tilt table can establish the diagnosis of orthostatic hypotension with more certainty Autonomic function can be assessed by observing blood pressure and heart rate responses to Valsalva maneuver and by tilt testing In older patients, vasoconstrictor abnormalities and autonomic insufficiency are perhaps the most common causes of syncope Thus, tilt testing should be done before proceeding to invasive studies unless clinical and ambulatory ECG evaluation suggests a cardiac abnormality
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