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Syncope: an Overview of Diagnosis and Treatment DAVID G BENDITT

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Syncope: an Overview of Diagnosis and Treatment DAVID G BENDITT ARTÍCULO DE REVISIÓN REV URUG CARDIOL 2011; 26: 55-70 Syncope:David G Benditt an overview of diagnosis and treatment Syncope: an overview of diagnosis and treatment DAVID G BENDITT. MD, FACC, FHRS, FESC, FRCPC 1 INTRODUCTION LOSS OF CONSCIOUSNESS Syncope is a syndrome in which a relatively Consciousness and ‘loss of consciousness’ sudden-onset, brief loss of consciousness re- (LOC) are complex concepts, but most physi- sults from a temporary self-terminating pe- cians have a working understanding of what riod of total cerebral hypoperfusion (1-4).In is meant (8). Essentially, LOC implies not only this regard, it is important to note that other loss of awareness and appropriate responsi- conditions (e.g., epilepsy, concussions, meta- veness to external stimuli, but also loss of bolic disturbances and intoxications) may al- postural tone. Occasionally, however, so cause a temporary loss of consciousness (T- symptoms may suggest that ‘syncope’ is im- LOC) but nonetheless are not ‘syncope’ (3-5). minent, but the full clinical picture does not Each of these differ from syncope either by evolve at that time; such cases are often ter- the need for medical intervention to reverse med ‘near-syncope’. In such instances, the pa- the process (e.g., hypoglycemia) or by the un- tient may experience near loss of vision derlying mechanism of the loss of conscious- (‘grey-out’ due principally to transient loss of ness (e.g., electrical disturbance in epilepsy, blood supply to the retina), diminution of hea- trauma in head injury, etc.) or both. Other ring, and feeling ‘out-of-touch’ with their su- conditions may also mimic syncope. These are rroundings and/or confused. On the other often termed ‘syncope mimics’ or ‘pseudosy- hand, many times patients complain of less ncope’, but differ from syncope inasmuch as well defined symptoms such as “dizziness” or they do not cause true loss of consciousness “lightheadedness”. These latter complaints (e.g., conversion reactions, malingering, and (especially in the elderly) may be due to an ill- cataplexy). defined functional cerebral dysfunction trig- In itself, ‘syncope’ is not a complete diag- gered by transient hypotension (perhaps not nosis. Identifying the cause is important, sin- severe enough to cause TLOC), but in most ce syncope may be a marker of increased mor- cases it is believed that such symptoms are tality risk in some cases, but even more often not related to either ‘syncope’ or ‘near- may lead to physical injury resulting from syncope’, and should not be reported as such. falls or accidents, diminished quality-of-life, and possible restriction from employment or avocation. The goal should be to determine EPIDEMIOLOGY AND SOCIAL COST OF SYNCOPE the cause of syncope with sufficient confiden- Syncope is known to be a relatively common ce to provide a reasonable assessment of prog- cause of emergency department evaluation nosis, recurrence risk, and treatment options. and hospital admission, but precise estimates The initial step is always the documentation of frequency are hard to establish, since in of a comprehensive and detailed medical his- many reports the precision with which synco- tory (3-7). pe has been differentiated from TLOC is un- clear. Given this limitation, various reports estimate that syncope accounts for 1% to 3% 1. Professor of Medicine, Co-Director Cardiac Arrhythmia Center, University of Minnesota Medical School. From the Cardiac Arrhythmia Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, MMC 508, 420 Delaware Street SE, Minneapolis, MN 55455, USA. Correspondence: David G Benditt MD. Mail Code 508, 420 Delaware St SE. Minneapolis, MN, 55455 Email [email protected] 55 REVISTA URUGUAYA DE CARDIOLOGÍA VOLUMEN 26 | Nº 1 | ABRIL 2011 Figure 1. Classification of the principal causes of syncope. See text for details. of emergency department visits and 1% to 6% Recent estimates place the proportion of of hospital admissions (1,2). emergency room visits due to syncope at An early report from the Framingham fo- about 1% in Italy, France, and the United llow-up study (9) found that only 3,2% of adults States (1,2). In the US, this translated into admitted to one or more syncope spells. By >1.127 million visits in 2006 based on ‘pri- contrast, in a more recent report from the sa- mary diagnoses’ recorded in the 2006 Natio- me study (10) noted that 10% of 7814 subjects nal Hospital Ambulatory Care survey, and admitted to at least one syncope spell over a >411,000 hospital admissions when syncope 17-year sampling time. In another extensive and collapse were listed among discharge community-based study of American adults diagnoses. aged 45 years and older, Chen et al (2006) (11) The direct cost of diagnosing and treating reported that 19% of adults admitted to at syncope is substantial. In the USA, an esti- least one syncope spell. Studies from Calgary mate of direct cost may be obtained from the (Canada), and Amsterdam (The Netherlands), Medicare database. In the year 2000 (20) the reported similar results for estimates of com- estimated total annual charges for syncope- munity lifetime cumulative incidence. Ganze- related admissions were $5.4 billion, with a boom et al (12) surveyed medical students and mean charge of $12,000 per hospitalization. found that 39% had fainted at least once. The Data in 2005-2006 from the United Kingdom Calgary group (13) reported that by age 60 provide estimates of £70 million per annum years 31% of males and 42% of females had (14,15). On the other hand, determining ‘total fainted, very similar to the proportions repor- cost’ is difficult since the indirect costs related ted by Amsterdam study (12,13). Thus, females to loss of earning by patients or family mem- were more likely to faint than males, or are at bers are much harder to measure. least more likely to volunteer the information. Taken together, the studies consistently sug- gest that 40% of people faint at least once in CLASSIFICATION OF THE CAUSES OF SYNCOPE their lives with females perhaps being somew- Syncope has many possible causes, and it is hat more susceptible. Further, within three essential to approach the diagnostic possibili- years of the initial episode, about 35% of pa- ties in an organized manner (Figure 1). Ho- tients experience recurrences. wever, even after a thorough assessment, it 56 SYNCOPE: AN OVERVIEW OF DIAGNOSIS AND TREATMENT DAVID G BENDITT TABLE 1. THE PRINCIPAL NEURALLY-MEDIATED REFLEX sively warm closed-in environments, or extre- SYNCOPE SYNDROMES me emotions. Common places for these events · Vasovagal (‘common’) faint are churches, restaurants and long queues. · Post-exercise variant Warning symptoms may occur, and include · Carotid Sinus Syndrome feeling: hot or cold, sweaty, tachycardic, · Situational faints: ‘short of air’, loss of hearing, nausea and – cough, – defecation, change in breathing pattern. Physical fin- – swallow, dings often reported by bystanders (if the – micturition, physician asks) in these cases include mar- – sneeze, ked pallor, damp and cold (“clammy”) skin, – swallow, and confusion. After the faint, if the patient is – venipuncture, permitted to remain recumbent, recovery – Other (e.g., brass instrument playing, weightlif- ting, postprandial) typically is very rapid, but a subsequent pe- · Glossopharyngeal and trigeminal neuralgia riod of fatigue of variable duration is quite · Inferior wall myocardial ischemia common. Typically, the diagnosis is made from the medical history alone and no testing is nee- may not be possible to assign a single cause ded. However, if the medical history does not for fainting. Patients often have multiple co- provide sufficient basis to make the diagno- morbidities and as a consequence they may sis, head-up tilt-table testing (HUT) may be have several equally probable causes of fain- helpful to support a diagnosis of vasovagal ting. syncope (19,20). Such testing, in the absence of pharmacological provocation, has a specifi- NEURALLY-MEDIATED REFLEX SYNCOPE SYNDROMES city of approximately 90%. HUT is not known Neurally-mediated reflex syncope refers to a to be useful in the other neurally-mediated group of related conditions in which sympto- reflex faints. matic hypotension occurs as a result of neural reflex vasodilatation and/or bradycardia (1,2). CAROTID SINUS SYNDROME The term ‘vasovagal syncope’ refers to a parti- Carotid sinus syndrome (CSS) and carotid si- cular type of neurally-mediated reflex syncope nus hypersensitivity (CSH) are two distinctly also known as the ‘common faint’ (16). Vasova- different entities. The first is a clinical syndro- gal syncope has many manifestations and is me resulting in syncope or near-syncope due to generally considered to encompass faints trig- bradycardia and/or vasodilatation secondary gered by emotional upset, fear, and pain, as to hypersensitivity of the carotid sinus baro- well as those occurring in less well-defined cir- roreceptor. CSH, on the other hand, is the cumstances. ‘Situational’ faints are essen- physiologic observation that may or may not tially identical to ‘vasovagal faints’, but occur have any clinical sequelae. If it is responsible as the result of readily identified triggers (e.g., for syncope, then the patient is diagnosed micturition, swallowing, etc). Carotid sinus with CSS. syndrome (CSS) also falls into this category. CSS is believed to be due to accidental ma- The neurally-mediated reflex faints, espe- nipulation of neck that results in external cially the vasovagal faint, are the most common pressure on the carotid sinus baroreceptors. causes of syncope overall, and are particularly The susceptible individual (usually older ma- prevalent in individuals without evidence of le patients >65 years of age or individuals underlying heart or vascular disease (Table 1). with previous neck surgery or irradiation) The principal pathophysiological mechanism is can often be demonstrated to exhibit carotid the triggering of a neural reflex resulting in sinus hypersensitivity (CSH) during delibe- both hypotension due to vasodilation and an rate diagnostic carotid sinus massage applied inappropriate chronotropic response (occasio- by a suitably experienced physician (21-23).
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