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

2. The importance of appropriate diagnostics a managementu of syncopy
Prognosis
The importance of appropriate diagnostics a managementu of syncopy
Soteriades et al. N Eng J Med, 2003.

3. Definition Loss of consciousness
Syncope is a T-LOC due to transient global cerebral hypoperfusion characterized by rapid onset, short duration, and spontaneous complete recovery.
T-LOC – wider term– all losses of consciousness independent of the pathophysiological cause
Loss of consciousness
Transient global hypoperfusion of brain
- circulatory cause
Sudden onset
Short duration
Spontaneous and full recovery
ESC Guidelines for the diagnosis and management of syncope (version 2009): Moya et al. Eur Heart J, 2009.

5. Clasification of syncope
Reflex syncope
Vasovagal
Situational
Carotid sinus hypersensitivity
Atypical forms
Orthostatic hypotension
Primary ANF
Secondary ANF
Iatrogenous
Volume depletion
Cardiac syncope
Arrhythmia as a primary cause
Structural heart disease

7. Initial workup Thorough history Physical examination
circumstances preceding the syncope, prodromal symptoms, what hapenned during (bystanders)
Personal/family history, sudden death?, medication, has it happened before?
Physical examination
Blood pressure lying down (5 mins) and standing (1st and 3rd min.)
ECG

8. Key questions What it really a syncope? Has a diagnosis been made?+
Risk?
High risk of cardiovascular event or sudden death?

9. Initial workup Suspected syncope Syncope Diagnosis Uncertain diagnosis
High risk
Early diagnostics and treatment
Low risk, recurrent
further workup
Low risk, isolated event
Diasnotics not indicated
Nonsyncopal T-LOC
Further workup, consultation of specialist, treatment

10. Risk stratificaion Structural heart disease
CAD (previous MI), heart failure, aortic stenosis, HCM
Clinical and ECG signs of arrhythmic etiology
Syncope lying down, physical activity, palpitations
Family history of sudden death
Bifascicular blocade, nsVT, susp. SSS, preexcitation, ↑QTc, Brugada, susp. ARVC
Age >40let + recurrent syncope (50% arrhytmia)
Serious comorbidities
Anemia, ionic imbalances

11. Further examination Diagnostic methods
Carotid massage
Pause > 3s, BP drop > 50 mmHg
Uncertain cause in pts > 40-yrs
Tilt test
Reflex syncope – cardioinhibitory, vasodepressor and mixed reacions
X orthostatic hypotension
Suspected reflex syncope, high risk pts. without cardiac cause, susp. OH, difdg. falls, epilepsy, pseudosyncopies

12. Further examination Diagnostic methods
ECG monitoration
During hospiralization
Suspected arrhythmic cause, high risk
Holter ECG (24h, 48h, 7d)
Recurrent syncopies/presyncopies
Implantable/external loop recorderd (ILR)
Recurent syncopies of unknown etiology, susp. VT with negative EP study
Diagnosis: syncope + arrhythia, serious arrhythmia
Syncope without ECG correlation rules out arrhythmic cause

13. Further examination Diagnostic methods
Electrophysiologic study
Restricted indications, suspected arrhythmic cause whithout non-invasice proof
Echocardiography
Risk stratification, dg. SOS
Stress test
Psychiatric examination
Neurological examination

15. Take home messages Not every LOC is a syncope.
A thorough history is utmost important.
Initial workup yields in diagnosis in about 25-40% of cases, in the other cases we stratify risk.
There are various diagnotic tests and therapeutic options. The basis is their reasonable and well-targeted use.