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

2. Neuro- Cardiogenic Syncope

3. Neuro- Cardiogenic Syncope
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

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

5. Neurocardiogenic Syncope
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

6. Neurocardiogenic Syncope
“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

7. Neurocardiogenic Syncope
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

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
Frequent somatic complaints without accompanying organic heart disease
(psycogenic)
Vertigo, dizartria, diplopia (Transient Ischemic Attack)

10. Neuro- Cardiogenic Syncope
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)

11. Neuro- Cardiogenic Syncope
Diagnostic Criteria – Certain (II)
Syncope secondary to cardiac ischemia;
ECG documentation of acute ischemia or infarction
Syncope secondary to cardiac arrhythmia ;
ECG documentation of
Sinüs bradycardia (< 40 beat/min or repetitive sinoatrial block or sinus pause > 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

12. Neuro- Cardiogenic Syncope
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
June 2004

13. Neuro - Cardiogenic Syncope

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

15. Neuro- Cardiogenic Syncope
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

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