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SYNCOPESYNCOPE Rasim Enar, M.D. Professor of Cardiology İstanbul University – Cerrahpaşa Medical Faculty Department of Cardiology Rasim Enar, M.D. Professor.

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Presentation on theme: "SYNCOPESYNCOPE Rasim Enar, M.D. Professor of Cardiology İstanbul University – Cerrahpaşa Medical Faculty Department of Cardiology Rasim Enar, M.D. Professor."— Presentation transcript:

1 SYNCOPESYNCOPE Rasim Enar, M.D. Professor of Cardiology İstanbul University – Cerrahpaşa Medical Faculty Department of Cardiology Rasim Enar, M.D. Professor of Cardiology İstanbul University – Cerrahpaşa Medical Faculty Department of Cardiology

2 Neuro- Cardiogenic Syncope

3 Syncope - Definition Syncope; is a transient loss of conciousness and postural tone with spontaneous recovery Loss of consiousness is a result of, sudden and shorterm serebral hipoperfusion Restoration of conciousness or orientation after a syncopal episode is usually immediate, and does nor require electrical or chemical therapy for reversal Neuro- Cardiogenic Syncope

4 1- 6 % of all hospital admissions 3 % of Emergency Department visits Prognosis – 1 year mortality risc Cardiogenic Syncope : 24 % Non-Cardiogenic Syncope : 4 % Neurocardiogenic Syncope Prevelans

5 Etiology – Cardiac Causes Anatomic causes Arrhythmic causes Aortic stenosis HOCM Myocardial ischemia / infarction Aortic dissection Cardiac tamponade Atrial myxoma Severe pulmonary hypertension Severe pulmonary emboli Subclavian steal syndrome Fallot tetralogy Tachy-arrhythmias - Supraventricular tachycardia - Ventricular tachycardia - Long-QT syndrome (primary /secondary) - Brugada syndrome Brady-arrythmia - Atrioventricular block - Pace-maker dysfunction - ICD dysfunction - Sinus node dysfunction / bradycardia Sick Sinus Syndrome Neurocardiogenic Syncope

6 Primary Evaluation Detailed clinical history obtained from the patient or the witness of the syncopal episode, about the period just before or after the episode will give clues about the etiology Ortostatic blood pressure measurements and careful physical examination including oscultation of cardiac murmurs and carotis bruits Standart ECG Neurocardiogenic Syncope

7 Classification of syncope Neurocardiogenic syndromes e.g. vasovagal, carotid sinus hypersensitivity, situational Ortostatic Primary cause : cardiac arrhythmia – conduction disturbances e.g. Bradycardia, Tachycardia, AV-Block, etc Structural cardiac or cardiopulmonary diseases e.g. acute myocardial infarction, aortic dissection, acute pulmonary emboli, etc Neurocardiogenic Syncope

8 Neuro- Cardiogenic Syncope Non-syncope seizures Syncope-like conditions, with loss or impairment of consciousness e.g. epileptic seizures, TIA, etc Syncope-like conditions, where the patient is conscious e.g. Psycogenic syncope (histerical, somatization disorders), etc

9 Neuro- Cardiogenic Syncope Clinical features associated with non-syncope seizure Post-seizure >5 min confusion (epileptic seizure) Long lasting tonic-clonic movements with the onset of the seizure (epileptic seizure) Frequent somatic complaints without accompanying organic heart disease (psycogenic) Vertigo, dizartria, diplopia (Transient Ischemic Attack)

10 Diagnostic Criteria – Certain (I) Vasovagal syncope; Syncope with typical prodromal symptoms which is provoked with fear, severe pain, emotional stress, catheter instrumentation, or after prolonged standing in hot enviorement Situational syncope; Syncope produced with vagal stimuli, like diüresis, frequeny coughing, defecation or swollowing Ortostatic syncope; Syncope or presyncope associated withg documented ortostatic hipotension (Sudden fall of SBP > 20 mmHg or < 90 mmHg) Neuro- Cardiogenic Syncope

11 Syncope secondary to cardiac ischemia; ECG documentation of acute ischemia or infarction Syncope secondary to cardiac arrhythmia ; ECG documentation of Sinüs bradycardia ( 3 second) Atrioventriküler block (2nd degree Mobitz Type II or 3rd degree) Alternating LBBB or RBBB Rapid paroxismal supraventricular tachycardia or ventricular tachtcardia Pace-maker dysfunction associated with cardiac pause Diagnostic Criteria – Certain (II) Neuro- Cardiogenic Syncope

12 June 2004 Diagnostic Criteria - Probable Conditions related with CARDIAC syncope ; Supine Post egzersize Post palpitation Known serious organic heart disease ECG disturbances - wide QRS complex (>0.12 sec) - AV conduction disturbances - Post-meal at 1 hour - Post egzersize - Following with new drug administration or after change of the dose Neuro- Cardiogenic Syncope

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14 Which patients should be hospitalised Syncope secondary to a cardiac pathology Syncope resulted with serious injury Frequent syncope attacks Neuro- Cardiogenic Syncope

15 Diagnostic Tests Carotid Sinus Massage Tilt Table Test Holter monitorörization Echocardiyography Egzersize Test External or Internal Loop Recorders Electrophysiologic Study (EPS) Cardiac Catheterisation and coronary anjiography Neurologic and pschchiatric evaluation Neuro- Cardiogenic Syncope

16 Syncope (unknown etiology) Probable Diagnosis (10%) Unclassified syncope (60%) Definite Diagnosis (10%) History, Physical Exam, ECG EchocardiographySpesific testsSpesific treatment & F/U Organic Heart Disease / Arrhythmia ?Vazovagal syncope ? EPSTilt Table Test Diagnosis (+) Diagnosis (-)Diagnosis (+) Diagnosis (-) Spesific tx & F/U Holter / Tilt TT Neuro- Cardiogenic Syncope

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