1. Syncope AM Report 6/25/10 Nicole Wilde

2. Syncope  Cause Not Obvious Neurally Mediated (vasovagal) 58% Cardiac Disease (arrhythmias) 23% Neurologic or Psychiatric disease 1% Unexplained 18% (41% in other studies) Syncope vs Fall vs TIA, etc…

4. History Number of episodes Associated Symptoms Prodrome (Auras) Sudden Onset Position Preceding Events Duration of Symptoms Medications and PMH

5. Physical Abnormal Vital Signs  Orthostatics  Irregular HR  Heart Sounds Neurological abnormalities Positive stool guiac

6. Orthostatics

7. ECG Sinus Bradycardia  3 sec Mobitz II second or third degree AV block Alternating Left and Right BBB VT or rapid paroxysmal SVT Pacemaker malfunction with pauses

8. Hospitalizations Suspected or known cardiac disease ECG abnormalities  arrhythmia Syncope during exercise Syncope causing severe injury Family History of Sudden Death Sudden onset of palpitations, syncope in supine position, frequent episodes  2004 ESC Syncope Guidelines

9. Work Up of Syncope Echo  Severe AS, Atrial Myxoma Exercise Testing  CAD, Heart Block, Autonomic Failure ECG, Telemetry, Holter Monitoring, External Event Recorder, Implantable Loop Recorder Carotid Sinus Massage Upright Tilt Table Test EEG and Psychiatric Evaluations EP Studies  Conduction system disease

10. Summary Majority of patients without heart disease with rare episodes  neurally mediated syncope and confirmation with tests are not needed Recurrent episodes  carotid massage, tilt testing, and prolonged ECG Neurological referral when autonomic failure or cerebrovascular steal suspected EEG or carotid doppler US not recommended when syncope most likely cause for LOC

12. Brugada Syndrome Sudden Cardiac Arrest ECG with pseudo RBBB and ST elevation in leads V1-V3 Coved and saddle back appearance Provoking factors: fever, drugs, electrolyte abnormalities, etc.

13. Brugada Syndrome

14. Autosomal Dominant, variable expression Mutations in SCN5A  cardiac sodium channel gene Sodium Channel blockers expose ECG changes ICD placement