Syncope

• Incidence and Prognosis
• Etiology and Diagnostic Approach
  • Syncope: etiology and diagnostic approach
  • Unexplained syncope--is screening for carotid sinus hypersensitivity indicated in all patients aged >40 years?
• Sudden transient loss of consciousness with associated loss of postural tone and spontaneous recovery
  • Results from transient cerebral hypoperfusion
• W/U: H+P, EKG, Labs (CBC, CMP, SaO2, Cardiac Enzymes)
  • Recurrent syncope, cardiac cause ruled out, atypical presentation, high risk occupation with single episode: Tilt-table tasting
    • 26-80% sensitive, 90% specific
  • Admit if any High risk (ROSE rule, BRACES):
    • High-Risk Features(≥1 feature increases the short-term risk of significant death or arrythmia)
      • Abnormal EKG (new change)
        • Diagnosis in 60%
      • History of structural heart disease or heart failure
        • Aortic Stenosis
      • Systolic BP <90mmHg at triage
      • Associated shortness of breath during syncope
      • Hematocrit <30%
      • Advanced age with CV co-morbidities
      • Family history of sudden cardiac death
    • BNP ≥300
    • Bradycardia ≤50
    • Rectal exam with FOB
    • Anemia (≤90)
    • Chest pain with syncope
    • EKG with Q wave (not in lead III)
    • Saturation ≤94% on RA
• Diagnosis and Management
  • No cause found: San Francisco Syncope Rules
  • Transient loss of consciousness synopsis of NIH guidelines
  • Association between symptoms and frequency of arrhythmias on 24-hour Holter monitoring
  • Usefulness of 24hr Holter monitoring in unexplained syncope and high likelihood of arrythmias
• Management
  • AAFP
  • European Guidelines 2009
  • Guideline for the Evaluation and Management of Patients With Syncope
  • All Patient: Orthostatic Vitals and EKG
    • Low-Risk: Ambulatory ECG monitor
    • Intermediate-Risk: Observation inpatient
    • High-Risk: Admission