1. Syncope diagnostic algorithm and management MUDr. Jakub Honěk Kardiologická klinika, 2.LF UK a FN Motol, Praha

2. Definition of syncope  Syncope is a T-LOC due to transient global cerebral hypoperfusion characterized by rapid onset, short duration, and spontaneous complete recovery.  T-LOC – all cases of transient loss of consciousness regardless of the pathophysiological mechanism Transient loss of consciousness Global cerebral hypoperfusion = circulatory cause Rapid onset Short duration Spontaneous complete recovery ESC Guidelines for the diagnosis and management of syncope (version 2009): Moya et al. Eur Heart J, 2009.

3. Significance, epidemiology  Risk of fall and trauma  A warning signal of sudden death  Mostly benign in young  A common complaint – 3% of emergency visits  A fraction of patients see a doctor  Bimodal age distribution

4. Prognosis, significance of syncope management and diagnostics Soteriades et al. N Eng J Med, 2003.

5. www.escardio.org/guidelines

6. Classification of syncope Reflex syncope Vasovagal Situational Carotid sinus hypersensitivity Atypical forms Syncope from ortostatic hypotension Primary ANF Secondary ANF Drug-induced Volume depletion Cardiac syncope Arrhythmia as a cause Structural heart disease

7. www.escardio.org/guidelines

8. Initial diagnostic work-up  A thorough history What preceded syncope, prodromes, eyewitness report, symptoms after syncope Personal and family history, medication, recurrent syncope?  Physical exam  BP supine and standing 5 min. supine, 1st and 3rd min. standing  ECG

9. Initial evaluation – key questions Syncope? Is it syncope? Diagnosis? Was diagnosis made? Risk? Is there a high-risk profile for casrdiovascular diseases or high sudden-death risk?

10. Initial evaluation Suspected syncopeSyncope Diagnosis made Diagnosis uncertain High-risk Admitt, diagnose, treat Low risk, recurrent Diagnose, treat? Low-risk, sporadic No further work-up NO Consider other diagnosis

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12. Initial evaluation Risk startification  Structural heart disease CHD (previous MI), heart failure, aortic stenosis, HCM…  Clinical or ECG signs suggestive of arrhytmic etiology Syncope while supine, exercising, palpitations Family history of sudden death Bifascicular block, nsVT, susp. SSS, preexcitation, ↑ QTc, Brugada, susp. ARVC Age >40 + recurrent syncope (50% arrhythmia)  Severe comorbidities Anemia, ion dysbalance

13. Further evaluation Diagnostic methods  Carotid massage Pause > 3s, BP drop > 50 mmHg Unknown cause in pts. > 40 yrs  Tilt test Reflex syncope - cardioinhibitory, vasodepresoric and mixed reaction X ortostatic hypotension Indicated in suspected reflex syncope, unknown etiology, susp. OH, difdg. of falls, pseudosyncope…

14. Further evaluation Diagnostic methods  ECG monitoring In-hospital monitoring  High-risk pts. Holter ECG (24h, 48h, 7d)  frequent syncope/presyncope Implantable/external loop recorder (ILR)  Recurrent syncope of unknown etiology, therapy- resistant epilepsy, susp. arrhytmic cause Arrhythmia during syncope or occurrence of severe arrhythmia make diagnosis, syncope with no ECG changes rule out arrhythmic cause

15. Further evaluation Diagnostic methods  Electrophysiological exam Specific indications, high suspicion not confirmed non-invasively  Echocardiography Risk stratification, structural heart disease  Stress test  Psychiatric evaluation  Neurological evaluation

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17. Take home messages  Not every LOC is a syncope  Thorough history is the cornerstone  Initial evaluation makes diagnosis 25- 40%, risk-stratification in the rest  There is plenty of diagnostic methos, use them wisely

18. Therapy Indications for permanent pacing  SSS + ECG correlated symptoms  SSS + abnormal CSNRT  Asymptomatic pauses >6s (SSS/AVB)  AVB II Mobitz II, AVB III  BBB + abnormal HV conduction  Alternating BBB  BBB + unexplained syncope – risk/ILR  Reflex cardio-inhibitory – „ultimum refugium“  Syncope due to hypersensitive carotid sinus