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Dr Sajeer K T Senior Resident Dept. of Cardiology MCH, Kozhikode 1.

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1 Dr Sajeer K T Senior Resident Dept. of Cardiology MCH, Kozhikode 1

2 Definition: Syncope is a transient loss of consciousness due to transient global cerebral hypo perfusion characterized by rapid onset, short duration, and spontaneous complete recovery - ESC 2009 Mechanism: Transient global cerebral hypoperfusion. Brignole et al. Europace. 6:467-537;2004 2

3 Impact of Syncope 40% will experience syncope at least once in a lifetime Major morbidity reported in 6% (e g: fractures, motor vehicle accidents) Minor injury in 29% (e g: lacerations, bruises) common medical problem ≈ 3% of ER visits ≈1-6 % of hospital admissions Brignole M, et al. Europace. 2003;5:293-298 3

4 Impact of Syncope 1 Linzer, J Clin Epidemiol, 1991. 2 Linzer, J Gen Int Med, 1994. Anxiety/ Depression Alter Daily Activities Restricted Driving Change Employment 73% 1 71% 2 60% 2 37% 2 Proportion of Patients

5 Syncope – A Symptom, Not a Diagnosis  Self-limited loss of consciousness and postural tone  Relatively rapid onset  Variable warning symptoms  Spontaneous, complete, and usually prompt recovery without medical or surgical intervention Brignole M, et al. Europace, 2004;6:467-537. Complete loss of consciousness in vasovagal syncope is usually no longer than 20 s in duration 5

6 Pre-syncope or near-syncope indicate symptoms and signs that occur before unconsciousness in syncope - Patients feels syncope is imminent - Symptoms associated with pre-syncope may be non-specific (e.g. dizziness) - tend to overlap the premonitory phase of true syncope ( light-headedness, nausea, sweating, weakness, and visual disturbances) - True Syncope should be differentiated from Nonsyncopal events a/w real or apparent transient LOC Causes of non-syncopal attacks (commonly misdiagnosed as syncope) European Heart Journal (2009) 30, 2631–2671 6

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8 Syncope Evaluation - Two main reasons to evaluate patients with syncope: 1. To determine the etiology of syncope 2. To stratify the risk of future adverse outcomes ESC syncope Neurally mediated Orthostatic Cardiac arrhythmia related Structural heart disease related Cerebrovascular syncope Brignole et al. Europace. 6:467-537;2004 8

9 Classification and Etiology of Syncope Orthostatic (11%) Cardiac Arrhythmia (14%) Structural Cardio- Pulmonary (4% 1 VVS CSS Situational  Cough  Post- Micturition 2 Drug-Induced Vol. Depletion ANS Failure  Primary  Secondary 3 Brady  SN Dysfunction  AV Block Tachy  VT  SVT L QT S Brugada Neurally- Mediated (24%) Unexplained Causes = Approximately 1/3 (34%) Cerebro- Vascular (12%) 5 Vascular steal synd. VBA disease Carotid.A disease 4 Acute Myocardial Ischemia Aortic Stenosis HCM Pulmonary Hypertension Aortic Dissection Brignole et al. Europace. 6:467-537;2004 9

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11 11 Classification of Syncope According to Etiology (Modified by ESC Guidelines ) Versus Classification According to Mechanism (Modified by ISSUE Classification J Am Coll Cardiol 2012;59:1583–91

12 Causes of syncope & Prevalence Linzer et al. Ann Intern Med 1997;126:989-96 12

13 13 Frequency of the causes of syncope in general population, Emergency Department and specialized clinical settings from some recent studies European Heart Journal (2009) 30, 2631–2671

14 14 BMJ 2010;340:c880 Causes of syncope by age

15 15 Frequency of the causes of syncope according to age European Heart Journal (2009) 30, 2631–2671

16 Clinical Features Suggestive of Specific Causes of Syncope  Episodes occur after sudden unexpected pain, fear, or unpleasant sight, sound, or smell  Episodes occur after prolonged standing at attention  Episodes occur in a well-trained athlete without heart disease after exertion Vasovagal attack Kapoor. NEJM, 1857 -1862; 2000 16

17 Episodes occur during or immediately after micturition, cough, swallowing, or defecation - Situational syncope Episodes occur with head rotation or pressure on carotid sinus (due to tumors, shaving, or tight collars) - Carotid-sinus syncope Episodes occur immediately on standing - Orthostatic hypotension Patient takes medications that may lead to a long QT interval or orthostasis and bradycardia - Drug-induced syncope Patient is confused after episode, or loss of consciousness lasts >5 minutes - Seizure Patient has a brief loss of consciousness with no prodrome and has heart disease - Arrhythmias Syncope occurs with exertion - AS, Pul.HTN, MS,HCM CAD Patient has frequent syncope with somatic symptoms but no heart disease - Psychiatric illness Kapoor. NEJM, 1857 -1862; 2000 17

18 Reflex syncope (neurally mediated syncope) Neurocardiogenic, Vasodepressor, Vasovagal syncope,Fainting Cardiovascular reflexes controlling the circulation become intermittently inappropriate (In response to a trigger) Resulting in vasodilatation and/ or bradycardia Fall in arterial BP and global cerebral perfusion 18 Brignole et al. Europace. 6:467-537;2004

19 Reflex syncope (neurally mediated syncope) Neurocardiogenic, Vasodepressor, Vasovagal syncope,Fainting - Common abnormality of blood pressure regulation characterized by the abrupt onset of hypotension with or without bradycardia - Triggers: - orthostatic stress ( prolonged standing ) - hot shower - emotional stress ( sight of blood) - Neurally mediated syncope results from a paradoxical reflex - initiated when ventricular preload is reduced by venous pooling 19

20 Venous pooling→ reduced ventricular preload ↓ in COP and BPsensed by arterial baroreceptors ↑ catecholamine levels Vigorously contracting vol-depleted ventricle Mechanoreceptors or C fibers (atria, ventricles, pulmonary artery) Afferent C fibers → dorsal vagal nucleus of the medulla Paradoxical withdrawal of peripheral sympathetic tone Increase in vagal tone Vasodilatation bradycardia syncope or presyncope 20

21 Vasodepressor type Reflex syncope-3 types ( based on efferent pathway) sympathetic or parasympathetic Cardioinhibitory typeMixed type Vasodilatation (↓BP) hypotension Bradycardia (↓HR) or Asystole ( predominate) Vasodilatation (↓BP) + Bradycardia (↓HR) 21 - ESC 2009

22 Etiology of CSS  Sensory nerve endings in the carotid sinus walls respond to deformation  “Deafferentation” of neck muscles may contribute  Increased afferent signals to brain stem  Reflex increase in efferent vagal activity and diminution of sympathetic tone results in bradycardia and vasodilatation Carotid Sinus

23 Orthostatic hypotension and orthostatic intolerance syndromes OH is defined as an abnormal decrease in systolic BP upon standing. 1.Classical OH : - a decrease in systolic BP ≥ 20 mmHg and in diastolic BP ≥10 mmHg within 3 min of standing - in patients with pure ANF, hypovolemia, or other forms of ANF 2.Initial OH: - Characterized by a BP decrease immediately on standing of > 40 mmHg, BP then spontaneously and rapidly returns to normal - period of hypotension and symptoms is short (< 30 s) J Neurol Sci 1996;144:218–219 23

24 J Neurol Sci 1996;144:218–219 (L) panel - healthy 17-year-old teenager with complaints of severe transient light headedness upon active standing, a pronounced initial fall in BP is observed. The nadir is at 7–10 s and followed by recovery of BP. (R) panel- 47-year-old male with pure ANF : BP starts to fall immediately after standing to very low levels after 1 min upright with little increase in HR despite the hypotension. Initial orthostatic hypotension ( L) V/S Classical orthostatic hypotension (R). 24

25 3.Delayed (progressive) OH : - slow progressive decrease in systolic blood pressure on standing - absence of a bradycardiac reflex (vagal) differentiates delayed OH from reflex syncope Reflex syncope (mixed form) induced by tilt testing : 1. 31-year-old patient (upper panel) And 2. 69-year-old patient (lower panel). Note the typical age differences with a much steeper fall in BP in the younger subject compared with the older subject 25

26 26 Syndromes of orthostatic intolerance which may cause syncope

27 27 Initial evaluation - Careful history - Physical examination (including orthostatic BP measurements) - ECG Initial evaluation should answer three key questions (1) Is it a syncopal episode or not? (2) Has the etiological diagnosis been determined? 3) Are there data s/o of a high risk CVS events or death? Diagnosis of syncope The following questions should be answered: 1. Was LOC complete? 2. Was LOC transient with rapid onset and short duration? 3. Did the patient recover spontaneously, completely and without sequelae? 4. Did the patient lose postural tone?

28 28 Risk stratification When cause of syncope remains uncertain after initial evaluation Assess the risk of major CVS events or SCD.

29 29 Risk stratification at initial evaluation in prospective population studies Table shows several different studies that have analysed the impact of different clinical data on the follow-up of patients presenting with syncope. ( presence of abnormal ECG, increased age, or data suggestive of heart disease imply a worse prognosis at 1–2 year follow-up) CHESS acronym Patients with syncope are at 25% risk for serious outcomes if they present with one of these five clinical conditions: 1. Congestive heart failure (CHF), 2.Hematocrit <30% 3. ECG abnormalities 4. Shortness of breath 5. Systolic blood pressure <90 mm Hg

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31 Diagnostic Tests  Ambulatory ECG Holter monitoring Event recorder ○ Intermittent vs. Loop ○ Implantable Loop Recorder (ILR)  Head-Up Tilt (HUT) Includes drug provocation (NTG, isoproterenol) Carotid Sinus Massage (CSM)  Adenosine Triphosphate Test (ATP) Brignole M, et al. Europace, 2004;6:467-537.

32 32 Diagnostic tests 1. Carotid sinus massage - Pressure at CCA bifurcation site produces a reflex slowing in heart rate and fall in blood pressure - Carotid sinus hypersensitivity (CSH): - a ventricular pause lasting > 3 s and/or - a fall in systolic BP of >50 mmHg - When CSH associated with spontaneous syncope → CSS.

33 33 Afferent limb arising from the mechanoreceptors of the carotid. A Carotid sinus reflex arc Midbrain centres ( vagal nucleus and the vasomotor centre) Efferent limb is via the vagal nerve and the parasympathetic ganglia to the sinus and atrioventricular nodes via the sympathetic nervous system to the heart and the blood vessels

34 Carotid Sinus Massage (CSM)  Method Massage, 5-10 seconds Don’t occlude Supine and upright posture (on tilt table)  Outcome >3 second asystole and/or > 50 mmHg fall in systolic BP with reproduction of symptoms = Carotid Sinus Syndrome  Absolute contraindications Carotid bruit, known significant carotid arterial disease, previous CVA( last 3 months )  Complications Primarily neurological Less than 0.2% Usually transient Kenny RA. Heart. 2000;83:564. Linzer M. Ann Intern Med. 1997;126:989. Munro N, et al. J Am Geriatr Soc. 1994;42:1248-1251.

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36 36 Tests for orthostatic challenge Changing from supine to upright position → displacement of blood from the thorax to the lower limbs → ↓ in venous return and CO In the absence of compensatory mechanisms→ a fall in BP may lead to syncope 2 methods: 1. Active standing: (in which patients arise actively from supine to erect) 2. Tilt table test : Brignole et al. Europace. 6:467-537;2004

37 37 Recommendations: active standing

38 38 Head-up tilt test (HUTT) Kenny et al (1986) : reported usefulness of HUTT in the investigation of patients with vasovagal syncope Protocols: - Patients should be fasted for 4 h prior to the test - Passive phase (20 min) + Sensitization phase (20 min) 1. low-dose intravenous isoproterenol test : incremental doses in order to increase average HR by 20–25% over baseline (usually ≤3 µg/min) 2. Sublingual nitro-glycerine protocol 300–400 µg of NTG after a 20 min unmedicated phase. - Both protocols have a similar rate of positive responses (61– 69%) - Specificity (92–94%) Arq Bras Cardiol 2011;96(3):246-254

39 39 Brignole M, et al. Europace, 2004;6:467-537.

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41 41 HUTT-Class I recommendation 1. Young patients without obvious or suspected heart disease with recurrent syncope of unexplained origin, in which the history is not typical enough for the diagnosis NMS. 2.In cases of a single episode of unexplained syncope, which occurred in situation where there is high risk of physical injury or with occupational implications HUTT- Class II recommendation 1. In the differentiation between convulsive syncope and epilepsy. 2. In diagnosis to differentiate between reflex syncope and OH 3. For the evaluation of patients unexplained recurrent falls. 4. When dealing with patients with presyncope or recurrent dizziness. 5. In the evaluation of patients with recurrent syncope and psychiatric illnesses.

42 42 - Table tilted at an angle of 70 degrees, with footrest and rest for the upper limb in which the BP will be measured. - The Velcro straps allow securing the patient in case of loss of postural tone. - The necessary equipment: - Device for non-invasive monitoring of BP (beat to beat) - BP curve - ECG monitoring devices Arq Bras Cardiol 2011;96(3):246-254 Head-up tilt test (HUTT)

43 43 A modified classification of VASIS (Vasovagal Syncope International Study) Arq Bras Cardiol 2011;96(3):246-254

44 44 A modified classification of VASIS (Vasovagal Syncope International Study) Arq Bras Cardiol 2011;96(3):246-254

45 45 A modified classification of VASIS (Vasovagal Syncope International Study) Arq Bras Cardiol 2011;96(3):246-254

46 46 Complications and contraindications - Tilt testing is safe - life-threatening ventricular arrhythmias with isoproterenol in the presence of IHD or sick sinus syndrome -No complications have been published with the use of NTG - Minor side effects are common- - Palpitations with isoproterenol - Headache with nitro glycerine Contraindications to the administration of isoproterenol : - IHD - uncontrolled HTN -left ventricular outflow tract obstruction - significant aortic stenosis

47 MethodComments Holter (24-48 hours)Not Useful for infrequent events Event Recorder  Useful for infrequent events  Limited value in sudden LOC Loop Recorder  Useful for infrequent events  Implantable type more convenient (ILR) Ambulatory ECG

48 The recording device is worn by the patient using a shoulder strap or belt loop, attaching to 3-5 skin electrodes for continuous monitoring. An event button (not shown) at the top of the housing of the device is pressed in the event of symptoms to mark the recording Holter Monitor Continuous ECG monitoring is possible for a maximum of 48 hours Current Cardiology Reviews, 2008, 4, 41-48

49 Patient ActivatorReveal ® Plus ILR9790 Programmer Reveal Plus Insertable Loop Recorder World J Cardiol 2010 ; 26 : 2(10): 308-315 Am J Cardiol, 1998;82:117-119.

50 50 Time-Dependent Cumulative Diagnostic Yield of ILR J Am Coll Cardiol 2012;59:1583–91

51 Diagnostic Assessment: Yields (N=341) Yield (%) Initial Evaluation History, Physical Exam, ECG 38-40 Other Tests/Procedures Head-Up Tilt27 External Cardiac Monitoring5-13 Insertable Loop Recorder (ILR)43-88 EP Study<2-5 J Am Coll Cardiol. 2001;37:1921-1928. Circulation. 2001;104:46-51

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53 Management Strategies for VVS  Optimal management strategies for VVS are a source of debate Patient education, reassurance, instruction Fluids, salts Tilt Training  Drug therapies  Pacing Class IIb indication for VVS patients with positive HUT and cardioinhibitory or mixed reflex

54 54 Goals of treatment: - Prevention of symptom recurrence and associated injuries - improved quality of life General principles of treatment of syncope: Initial treatment: 1.Education regarding avoidance of triggering events (hot crowded environments, volume depletion, effects of cough, tight collars) 2. Recognition of premonitory symptoms 3. Manoeuvres to abort the episode (e.g. supine posture, physical Counter pressure manoeuvres (PCMs)) 4.Careful avoidance of agents lowering BP: : alpha-blockers, diuretics, alcohol

55 55 Additional treatment may be necessary in high risk or high frequency settings when:  syncope is very frequent (e.g. alters the quality of life )  syncope is recurrent and unpredictable (absence of premonitory symptoms) and exposes patients at high risk of trauma  syncope occurs during the prosecution of a high risk activity (e.g., driving, machine operator, flying, competitive athletics). Treatment is not necessary in patients who have sustained a single syncope and are not having syncope in a high risk setting.

56 56 Physical counter pressure manoeuvres Isometric PCMs - induce a significant increase in BP - leg crossing - hand grip and arm tensing - Mediated largely by sympathetic nerve discharge - Vascular resistance increase during manoeuvres - Mechanical compression of the venous vascular bed in the legs and abdomen J Am Coll Cardiol 2006;48:1652–7

57 VVS - Tilt Training Protocol  Objectives Enhance orthostatic tolerance Diminish excessive autonomic reflex activity Reduce syncope susceptibility/recurrences  Technique Prescribed periods of upright posture against a wall Start with 3-5 min BID Increase by 5 min each week until a duration of 30 min is achieved Reybrouck T, et al. PACE. 2000;23:493-498.

58 VVS: Pharmacologic treatment  Salt /Volume Salt tablets fludrocortisone  Beta-adrenergic blockers  Disopyramide  SSRIs Paroxetine  Vasoconstrictors Midodrine Etilephrine

59 The Role of Pacing as Therapy for Syncope  VVS with +HUT and Cardioinhibitory response: - Class IIb indication for pacing  Three randomized, prospective trials reported benefits of pacing in select VVS patients: VPS I VASIS SYDIT  Subsequent study results less clear VPS II Synpace Connolly SJ. J Am Coll Cardiol. 1999;33:16-20. Sutton R. Circulation. 2000;102:294-299. Ammirati F. Circ. 2001;104:52-57.

60 VPS I (North American Vasovagal Pacemaker Study)  Objective: To evaluate pacemaker therapy for severe recurrent vasovagal syncope  Randomized, prospective, single center  N=54 patients 27: DDD pacemaker with rate drop response 27: No pacemaker  Inclusion: ≥ 6 lifetime episodes of syncope & +ve HUT  Primary outcome: First recurrence of syncope Connolly SJ. J Am Coll Cardiol. 1999;33:16-20.

61 100 90 80 70 60 50 40 30 20 10 0 03691215 Time in Months No Pacemaker (PM) 2P=0.000022 Pacemaker Cumulative Risk (%) Connolly SJ. J Am Coll Cardiol. 1999;33:16-20. Results: 6/27 (22%) with PM had recurrence vs. 19/27 (70%) without PM 84% RRR (2p=0.000022) VPS I (North American Vasovagal Pacemaker Study)

62 VASIS (VAsovagal Syncope International Study)  Objective: To evaluate pacemaker therapy for severe cardioinhibitory tilt- positive neurally mediated syncope  Randomized, prospective, multi-center  N=42 patients 19: Dual chamber pacemaker with rate hysteresis 23: No pacemaker  Inclusion: Positive cardioinhibitory response  Primary outcome: First recurrence of syncope Sutton R. Circulation. 2000;102:294-299.

63 Pacemaker (PM) No Pacemaker p=0.0004 Years % Syncope-Free 100 80 60 40 20 023456 Results: 1/19(5%) with PM had recurrence vs. 14/23 (61%) without PM VASIS (VAsovagal Syncope International Study)

64 SYDIT (SYncope Diagnosis and Treatment)  Objective: To compare the effects of cardiac pacing with pharmacological therapy in patients with recurrent vasovagal syncope  Randomized, prospective, multi-center  N=93 patients 46: DDD pacemaker with rate drop response 47: Atenolol 100 mg/d  Inclusion: Positive HUT with relative bradycardia  Primary outcome: First recurrence of syncope Ammirati F. Circulation. 2001;104:52-57.

65 SYDIT (SYncope DIagnosis and Treatment) Ammirati F. Circulation. 2001;104:52-57. 0.6 0.7 0.8 0.9 1.0 01002003004005006007008009001000 Drug Pacemaker (PM) Time (Days) % Syncope-Free p=0.0032 Results: 2/46 (4%) with PM had syncope recurrence vs. 12/47 (26%) without PM

66 VPS II (Vasovagal Pacemaker Study II)  Objective: To determine if pacing therapy reduces the risk of syncope in patients with vasovagal syncope  Randomized, double-blind, prospective, multi-center  N=100 patients 52: Only sensing without pacing 48: DDD pacemaker with rate drop response  Inclusion: Positive HUT with (HR x BP) < 6000/min x mm Hg  Primary outcome: First recurrence of syncope Connolly S. JAMA. 2003;289:2224-2229.

67 Dual Chamber Pacing (DDD) Only Sensing Without Pacing (ODO) 1.0 0.8 0.6 0.4 0.2 0 Months Since Randomization Cumulative Risk 6 5 4 3 2 1 0 Connolly S. JAMA. 2003;289:2224–2229. Results: 16/48 (33% ) with pacing had recurrence vs. 22/52(42% ) with only sensing (not statistically significant) VPS II (Vasovagal Pacemaker Study II)

68 SYNPACE (Vasovagal SYNcope and PACing)  Objective: To determine if pacing therapy will reduce syncope relapses in patients with recurrent vasovagal syncope, compared to those with a pacemaker programmed to OFF  Randomized, double-blind, prospective, multi-center, placebo-controlled  N=29 patients 16: DDD PM with rate drop response programmed ON 13: PM programmed OFF (OOO mode)  Inclusion: Recurrent VVS and +HUT with asystolic or mixed response  Primary outcome: First recurrence of syncope Raviele A, et al. Eur Heart J. 2004;25:1741-1748.

69 SYNPACE (Vasovagal SYNcope and PACing) Results: 8/16(50%) with pacing ON had recurrence vs. 5/13 (38%) with pacing OFF (not statistically significant) 0.6 0.7 0.8 0.9 1.0 02004006008001000 Pacemaker OFF % Syncope-Free p=0.58 0.5 0.4 0.3 0.2 0.1 0.0 Pacemaker ON Days Since Randomization Raviele A, et al. Eur Heart J. 2004;25:1741-1748.

70 Role of Pacing as Therapy for Syncope: Summary  Pacemaker implantation may modulate reflex syncope and autonomic responses  Study results may differ based on pre-implant selection criteria and tilt-testing techniques  Pacing therapy is effective in some but not all (cardioinhibition vs. vasodepression)  In five pacing studies, syncope recurred in 33/156 (21%) of paced patients, 72/162 (44%) in non-paced patients (p<0.000) Kapoor W. JAMA. 2003;289:2272-2275.

71 CSS : Role of Pacing – Syncope Recurrence Rate  Class I indication for pacing (AHA and HRS)  Limit pacing to CSS that is: Cardioinhibitory Mixed  DDD/DDI superior to VVI If the diagnosis of CSH is based on a >3-second pause with carotid sinus massage without clear, provocative events, pacemaker implantation is less strongly recommended (Class IIa).

72 VVS Pacing Trials Conclusions DDD pacing reduces the risk of syncope in patients with recurrent, refractory, highly-symptomatic, cardioinhibitory vasovagal syncope.

73 SAFE PACE Syncope And Falls in the Elderly – Pacing And Carotid Sinus Evaluation  Objective Determine whether cardiac pacing reduces falls in older adults with carotid sinus hypersensitivity  Randomized controlled trial (N=175) Adults > 50 years, non-accidental fall, positive CSM Pacing (n=87) vs. No Pacing (n=88)  Results More than 1/3 of adults over 50 years presented to the ER because of a fall With pacing, falls  70% Syncopal events  53% Injurious events  70% Kenny RA. J Am Coll Cardiol. 2001;38:1491-1496.

74 SAFE PACE  Conclusions Strong association between non-accidental falls and cardioinhibitory CSH Cardiac pacing significantly reduced subsequent falls CSH should be considered in all older adults who have non-accidental falls Kenny RA, J Am Coll Cardiol. 2001; 38:1491-1496.

75 Conclusion  Syncope is a common symptom with many causes  Deserves thorough investigation and appropriate treatment  A disciplined approach is essential  ESC guidelines offer current best practices

76 76 1.Guidelines for the diagnosis and management of syncope (version 2009)- The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC)-European Heart Journal (2009) 30, 2631–2671 2.Guidelines on Management (Diagnosis and Treatment) of Syncope Update 2004 Europace (2004) 6, 467e537 3.Kapoor- Syncope Review article New Eng J Med 2000, 12; 1856-1867 4. Steve W Parry, Maw Pin Tan- clinical review- An approach to the evaluation and management of syncope in adults BMJ 2010;340:c880 5.Paula Gonçalves Macedo Tilt Test - from the Necessary to the Indispensable. Arq Bras Cardiol 2011;96(3):246-254 6. Rajesh Subbiah Syncope: Review of Monitoring Modalities Current Cardiology Reviews 2008, 4, 41-48 7.Michele Brignole, New Concepts in the Assessment of Syncope J Am Coll Cardiol 2012;59:1583–91 8. Kapoor- Current evaluation of syncope Circulation. 2002;106:1606-1609 9.Paolo Alboni Diagnostic Value of History in Patients With Syncope With or Without Heart Disease J Am Coll Cardiol 2001;37:1921–8 10.Nynke van DijkEffectiveness of Physical Counterpressure Maneuvers in Preventing Vasovagal Syncope The Physical Counterpressure Manoeuvres Trial (PC-Trial) J Am Coll Cardiol 2006;48:1652–7 11.Nevin T Wijesekera, Arvinder S Kurbaan Pacing for Vasovagal Syncope. Indian Pacing and Electr. Journal 2002 2(4): 114-119 12.Blair P. Grubb, M.D Neurocardiogenic Syncope N Engl J Med 2005;352:1004-10. REFERENCES

77 77 13. Joanne L.Evaluation and Management of Syncope Clinical Scholars Review, Vol. 2, No. 2, 2009 14. Attilio Del Rosso Relation of Clinical Presentation of Syncope to the Age of Patients Am J Cardiol 2005;96:1431–1435 15.Chad Kessler The Emergency Department Approach to Syncope: Evidence-based Guidelines and Prediction Emerg Med Clin N Am 28 (2010) 487–50 16. STUART J. The North American Vasovagal Pacemaker Study (VPS) A Randomized Trial of Permanent Cardiac Pacing for the Prevention of Vasovagal Syncope J Am Coll Cardiol 1999;33:16–20 17. Richard Sutton et al.Dual-Chamber Pacing in the Treatment of Neurally Mediated Tilt-Positive Cardioinhibitory Syncope Pacemaker Versus No Therapy: A Multicenter Randomized Study Circulation. 2000;102:294-299 18. Fabrizio Ammirati et al. Permanent Cardiac Pacing Versus Medical Treatment for the Prevention of Recurrent Vasovagal Circulation. 2001;104:52-57 19. Rose Anne M. Kenny Carotid Sinus Syndrome: A Modifiable Risk Factor for Non accidental Falls in Older Adults (SAFE PACE) J Am Coll Cardiol 2001;38:1491– 6 20. Ward.Midodrine: a role in the management of neurocardiogenic syncope. Heart 1998;79:45–49 21. Peter et al. Fludrocortisone in neurally mediated hypotension chronic fatigue syndrome JAMA 2001; 285: 52-59. 22. Antonio Raviele et al. Effect of Etilefrine in Preventing Syncopal Recurrence in Patients With Vasovagal Syncope -A Double-Blind, Randomized, Placebo-Controlled Trial Circulation. 1999;99:1452-1457. 23. Enrico Di Girolamo et al. Effects of Paroxetine Hydrochloride : A Selective Serotonin Reuptake Inhibitor, on Refractory Vasovagal Syncope: A Randomized, Double-blind, Placebo-controlled Study J Am Coll Cardiol 1999;33:1227–30.

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79 MCQs  1. Drugs proven to be useful in VVS except  A) Midodrine  B) Etilefrine  C) Fludrocortisone  D) Paroxetine  E) Atenolol 79

80  2). Carotid sinus hypersensitivity (CSH) : incorrect ?  A) a ventricular pause lasting > 3 s  B) a fall in systolic BP of >50 mmHg  C) A & B  D) BP < 100 mm Hg 80

81  3). Investigation with highest diagnostic yield in evaluation of syncope?  A) Holter  B) EP study  C) ILR  D) TMT 81

82  4) True about HUTT  A) Passive phase 40 min+ sensitization phase 40 min  B) isoproterenol contraindicated in IHD  C) done in all cases of syncope evaluation  D) gold standard for NMS evaluation 82

83  5) Contraindications to the administration of isoproterenol except? :  a) - IHD  b) - hypotension  c) -left ventricular outflow tract obstruction  -d) significant aortic stenosis 83

84 6. trials showing benefit of pacing in VVS except? VPS I VASIS SYDIT Synpace 84

85 85  7. All are CHESS acronym in SFS score except?  1. Congestive heart failure (CHF)  2.Hematocrit <30%  3. ECG abnormalities  4. Angina  5. Systolic blood pressure <90 mm Hg

86  8) True about CSS except? a) Sensory nerve endings in the carotid sinus walls respond to deformation  B) “Deafferentation” of neck muscles may contribute  C) Increased afferent signals to brain stem  Reflex decrease in efferent vagal activity and diminution of sympathetic tone results in bradycardia and vasodilatation 86

87  9. True about pacing in NMS except?  A) class I recommendation in CSS  B) Calss II b recommendation In VVS  C) DDD with rate drop response is preferred  D) none 87

88  10. All are trials in VVS except?  A) VPS 1  B) Issue 3  C) VASIS  D) SAFE pace trial 88

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