SWOONING AND VAPORS Syncope and near syncope

Syncope accounts for 3% ER visits Syncope/pre-syncope symptoms are due to a reduction in cerebral perfusion, most often as result of decreased blood pressure.

Blood pressure is dependent on Cardiac output Vascular tone Vascular volume

Cardiac output HEART RATE: too slow/fast, arrhythmias MECHANICAL: aortic/mitral stenosis; pulmonary emboli; HOCUM; Cardiomyopathy

VASCULAR VOLUME Blood loss dehydration

VASCULAR TONE Drugs Neuromediated Autonomic insuffiency Orthostasis Vascular disease-carotid, vertebralbasilar

CAUSES OF SYNCOPE Cardiac:14% arrhythmia/ 4% mechanical Neurologic: 10% Neurally mediated: Vasovagal 18-25% Orthostatic: 8-10% Psychiatric: 2% No clear etiology 33-45%

PROGNOSIS VARIES WITH ETIOLOGY Cardiac syncopeNon-cardiac syncope – 25% 1 year mortality-7% 1 year mortality – 14% 1 year CSD-3% 1 year CSD

HISTORY AND PHYSICAL More than 50% of diagnosis should come from History and Physical

Prior incidence? Behavior at time of event Symptoms prodrome? Duration of LOC? Mental status afterwards Witness information?

BEHAVIOR/CONDITIONS Postural change Cough Swallowing Head turning/neck pressure Defecation Pain Strong emotion Prolonged standing At rest or with activity Tremor seizure activity

Symptoms Nausea Pallor Warmth/flushed Diaphoresis Palpitations Visual/hearing changes Confusion headache

Duration of LOC/event seconds-hours Mental status after postictal/washed out Witness information

Past medical History Structural heart disease Previous heart rhythm problems Seizure history Vascular disease Drugs and recent changes

PHYSICAL EXAM Vital signs, including orthostatic blood pressures->20 mmHg drop in BP with standing Carotid hypersensitivity>3 sec pause, 50 mmHg asymptomatic or 30 mmHg symptomatic BP drop (up to 5 sec massage) Bruits Murmur Neurological findings

diagnostics ECG 5% unselected diagnostic yield – Long QT; afib/flutter; MAT; paced; VPB; V tach; bundle branch block; LVH; Old MI;WPW; Mobitiz type II – ECHO: 5-10 %unselected diagnostic yield – EST: activity associated symptoms – Monitor holter/event monitor – Tilt table test

NEUROCARDIOGENIC SYNCOPE Very common 20-25% in most series Usually manifests by second decade of life Abnormal reflex-mediated – Usually upright position – Trigger/prodrome – Decreased venous return; increased LV contractility; mechanical receptor activation— leads to—vasodilatation/bradycardia—manifests as hypotension-syncope

SYCOPE DIAGNOSIS SCORING SYSTEM PATIENT FEATUREPOINTS Female, <42 yrs7 Syncope/presyncope – Headache/flushing/pain3 for each – Nausea2 – Diaphoresis2 – Male <43 yrs2 – Prolonged orthostasis1 – Cyanosis-4 – Diabetes-4 – Bifasicular block-3 – Chest pain with fainting-2 – Postictal confusion-1 – Memory of fainting-1 – Score 3 or > vasovagal syncope; score 2 or less another source

NEUROCARDIOGENIC SYNCOPE Triggers: pain; strong emotion/stress; prolonged standing Situational: micturation; defication; cough; deglutation

PREDICTORS OF POOR OUTCOME IN SYNCOPE PATIENTS Abnormal ECG-non-specific ST or sinus tachycardia Prior ventricular arrhythmia >10VPB/hr; VPB pairs; multifocal VPB CHF history Age >45 years (without prior history of syncope) If 05% 1year arrhythmia/death If 110% If 3-460%

WHEN TO HOSPITALIZE History of chest pain Hx of CAD, CHF, Ventricular ectopy Evidence of CHF,AS, focal neuro defect ECG abnl.-BBB; ischemia; MI;arrhythmia Consider-for exertional syncope; frequent spells; age >70 yr; orthostasis; sustained physical injury; suspected ACS