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Syncope 2017
- 1. LOGO 2017 ACC/AHA/HRS Guideline forthe Evaluation and Management of Patients With Syncope DR DANG QUY DUC CARDIOLOGY DEPARMENT CHO RAY HOSPITAL CHF SYM 030 26-12-2017
- 2. Canada Canadian CardiovascularSociety (CCS) and Canadian Pediatric Cardiology Association (CPCA): Society position statement on the approach to syncope in the pediatric patient (2017) Choosing Wisely Canada: Don't order CT head scans in adult patients with simple syncope in the absence of high-risk predictors (2016) Choosing Wisely Canada: Don't routinely obtain neuro-imaging studies (CT, MRI scans, or carotid Doppler ultrasonography) in the evaluation of simple syncope in patients with a normal neurological examination (2015) CCS: Society position statement – Standardized approaches to the investigation of syncope (2011) United States American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS): Guideline for the evaluation and management of patients with syncope (2017) Choosing Wisely: Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma and a normal neurological evaluation (2014) Choosing Wisely: Don't perform imaging of the carotid arteries for simple syncope without other neurologic symptoms (2013) Choosing Wisely: In the evaluation of simple syncope and a normal neurological examination, don't obtain brain imaging studies (CT or MRI) (2012) American College of Emergency Physicians (ACEP): Clinical policy – Critical issues in the evaluation and management of adult patients presenting to the emergency department with syncope (2007) AHA/American College of Cardiology Foundation (ACCF): Scientific statement on the evaluation of syncope (2006) Europe European Society of Cardiology (ESC): Guidelines for the diagnosis and management of syncope (2009) United Kingdom National Institute for Health and Care Excellence (NICE): Clinical guideline – Transient loss of consciousness ("blackouts") in over 16s (2010, updated 2014) NICE: Quality standard – Transient loss of consciousness ("blackouts") in over 16s (2014) Japan Japanese Circulation Society (JCS): Guidelines for diagnosis and management of syncope (2011, revised 2012)
- 3. LOGO Contents GENERAL PRINCIPLES1 EVALUATION ANDDIAGNOSIS2 TREATMENT3 EVIDENCE GAPS4
- 4. LOGO 1-3% ED visitsand hospital admissions in USA. Prevalence rates: 41%, with recurrent syncope 13.5%. Minnesota (USA): Prevalence 19%; Females: (22% versus 15%;p<0.001). Older patients: 7% annual incidence of syncope, 30% 2- year recurrence rate.
- 5. LOGO SYNCOPE 1. A symptom: with an abrupt, transient, complete loss of consciousness, inability to maintain postural tone, rapid and spontaneous recovery. 2. Seizure, head trauma. 3. Mechanism: cerebral hypoperfusion.
- 6. LOGO Loss of consciousness Acognitive state: lacks awareness of oneself and one’s situation, inability to respond to stimuli.
- 7. LOGO Transient loss ofconsciousness Self-limited loss of consciousness Mechanism: cerebral hypoperfusion
- 8. LOGO Cardiac syncope bradycardia, tachycardia,or hypotension. low cardiac index, blood flow obstruction, vasodilatation, or acute vascular dissection
- 9. LOGO OTHER SYNCOPE Reflex syncopeOrthostatic hypotension Postural orthostatic tachycardia syndrome a reflex that causes vasodilation, bradycardia, or both A drop in systolic BP of ≥ 20 mm Hg or diastolic BP of ≥ 10 mm Hg with assumption of an upright posture an increase in heart rate of ≥ 30 bpm during a positional change from supine to standing (or ≥ 40 bpm in those 12–19 1. Vasovagal syncope. 2. Carotid sinus syndrome. 3. Situational syncope
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- 18. LOGO EVALUATION Cardiac Arrhythmic Conditions Cardiac orVascular Nonarrhythmic Conditions Noncardiac Conditions 1. Sustained or symptomatic VT 2. Symptomatic conduction system disease or Mobitz II or third-degree heart block 3. Symptomatic bradycardia or sinus pauses not related to neurally mediated syncope 4. Symptomatic SVT 5. Pacemaker/ICD malfunction 6. Inheritable cardiovascular conditions predisposing to arrhythmias 1. Cardiac ischemia 2. Severe aortic stenosis 3. Cardiac tamponade 4. HCM 5. Severe prosthetic valve dysfunction 6. Pulmonary embolism 7. Aortic dissection 8. Acute HF 9. Moderate-to-severe LV dysfunction. 1. Severe anemia/gastrointestinal bleeding 2. Major traumatic injury due to syncope 3. Persistent vital sign abnormalities
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- 21. LOGO Autonomic Evaluation Centralor peripheral autonomic nervous system damage or dysfunction. Weakness, fatigue,visual blurring, cognitive slowing, leg buckling, the “coat hanger” headache → provoked or exacerbated by exertion, prolonged standing, meals, or increased ambient temperature.
- 22. LOGO Autonomic Evaluation Centralautonomic disorders: multiple system atrophy, Parkinson’s disease, Lewy Body dementia. Peripheral autonomic dysfunction: pure autonomic failure, neuropathies due to diabetes amyloidosis, immune-mediated neuropathies, hereditary sensory and autonomic neuropathies, inflammatory neuropathies, vitamin B12 deficiency, neurotoxic exposure, HIV and other infections, and porphyria.
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- 24. LOGO POTS 1) Symptoms occurstanding (lightheadedness, palpitations, tremulousness, generalized weakness, blurred vision, exercise intolerance, and fatigue) 2) an increase in heart rate of > 30 bpm during a positional change from supine to standing (or > 40 bpm in those 12–19) 3) the absence of OH. Postural orthostatic tachycardia syndrome
- 25. LOGO POTS 2015 Heart RhythmSociety Expert Consensus Statement on the Diagnosis and Treatment of POTs
- 26. LOGO Neurological Diagnostics EEG, CT,MRI, and carotid ultrasound. very limited value in the context of syncope evaluation and management, the diagnostic yield is low, very high cost per diagnosis. not recommended in the routine valuation of patients with syncope in the absence of focal neurological findings.
- 27. LOGO Reflex evaluation Vasovagal syncope Carotid Sinus Syndrome Situational syncope hypotensionand/or bradycardia Prolonged standing or exposure to emotional stress, pain, or medical procedures a pause > 3 s and/or a decrease of systolic pressure > 50 mm Hg occurs upon stimulation of the carotid sinus coughing, laughing, swallowing, micturition, or defecation
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- 29. LOGO Pseudosyncope 1. young females 2.history of physical and/or sexual abuse. 3. loss of consciousness is often long (5 to 20 minutes), and episodes are frequent. 4. other characteristics: closed eyes, lack of pallor and diaphoresis, and usually little physical harm. 5. normal pulse, blood pressure, or EEG during pseudosyncope.
- 30. LOGO CARDIACVASCULAR SYNCOPE Arrhythmic Conditions Bradycardia Supraventricular Tachycardia VentricularArrhythmia StructuralConditions Ischemic and Nonischemic Cardiomyopathy Valvular Heart Disease Hypertrophic Cardiomyopathy Arrhythmogenic Right Ventricular Cardiomyopathy Cardiac Sarcoidosis Inheritable Arrhythmic Conditions Brugada Syndrome Short-long QT Syndrom Catecholaminergic Polymorphic Ventricular Tachycardia Early Repolarization Syndrom
- 31. LOGO Adult Congenital Heart Disease referralto a specialist with expertise in ACHD can be beneficial. EPs is reasonable in patients with moderate or severe ACHD and unexplained syncope.
- 32. LOGO Athletes Cardiovascular assessment Assessment bya specialist with disease- specific expertise Extended monitoring Not recommended for athletes with syncope and phenotype-positive HCM, CPVT, LQTS1, or ARVC.
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Editor's Notes
- #5 1 to 3 percent of all ED visits and hospital admissions in the United States [2-6]. Approach to the adult patient with syncope in the emergency department. Studies of syncope report prevalence rates as high as 41%, with recurrent syncope occurring in 13.5% [43]. Older institutionalized patients have a 7% annual incidence of syncope, a 23% overall prevalence, and a 30% 2-year recurrence rate. [56]. Females reported a higher prevalence of syncope (22% versus 15%, p,0.001).[44]