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Syncope: Overview and Approach to Management

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Syncope: Overview and Approach to Management SMAC01 01/21/2005 09:57 AM Page 1 1 CHAPTER 1 Syncope: Overview and approach to management Brian Olshansky, MD “near-syncope”), falling episodes, and coma are Introduction often confused with, and inappropriately labeled Syncope is a common, important medical problem as, “true” syncope. Distinction between sleeping, caused by many conditions, ranging from benign confusion, intoxication, and fainting may not be and self-limiting to chronic, recurrent, and poten- completely clear. To make matters more difficult, tially fatal causes. Unfortunately, differentiation an elderly patient, already confused, may fall and between benign and malignant causes can be diffi- pass out with only vague recall of the event. Such a cult and challenging. Even with knowledge of com- patient may even think he or she passed out when mon syndromes and conditions that cause syncope, nothing of the sort occurred. This diverse collec- and guidelines [1], an effective approach to the tion of clinical presentations perplexes the patient problem requires careful integration of clues pro- and the physician. Episodes can be difficult to define vided in the history and physical examination com- even with careful observation, and the mechanism bined with keen clinical acumen. Management of may be confusing even with extensive monitoring. this baffling problem can be frustrating, confusing, True syncope is an abrupt but transient loss of and often unrewarding. Treatment can be imposs- consciousness associated with absence of postural ible to prescribe without a clear understanding of tone followed by rapid, usually complete, recovery the cause, and treatments may be directed to risk as without the need for intervention to stop the epis- well as symptom reduction. ode. A prodrome may be present. While alarming, Fortunately, experienced, astute, circumspect this symptom is non-specific. It is generally trig- clinicians can deliver effective care when careful gered by a process that results in abrupt, transient attention is paid to detail. This chapter considers a (5–20 s) interruption of cerebral blood flow, spe- general overview of the problem of syncope and cifically to the reticular activating system. provides guidelines on how to approach manage- Collapse, associated with syncope, can be mis- ment. Reference is given to other chapters in this interpreted. In one study of 121 patients admitted book that provide more detail on specific topics. to the emergency room with “collapse” as the admitting diagnosis, 19 had cardiac arrest, four were brought in dead and one was asleep [2]. Only Definitions 15 were ultimately diagnosed as having fainted. Syncope is often considered with several more The final diagnosis in eight was still “collapse.” vague symptoms that are manifestations of many Primary neurological or metabolic derangements clinical conditions. “Spells,” transient confusion or can also mimic, but rarely cause, true syncope. weakness, dizziness, loss of memory, lightheaded- Also, syncope can mimic a seizure or a metabolic ness, near loss of consciousness (“presyncope” or derangement. 1 SMAC01 01/21/2005 09:57 AM Page 2 2 CHAPTER 1 Syncope: Overview and approach to management employment [9]. Seventy-three percent become Importance of syncope anxious or depressed, especially if a cause is not “The only difference between syncope and found and treated [10,11]. sudden death is that in one you wake up.” [3] (vive la différence) [4] Syncope can cause injuries. Injuries from syncope occur in 17–35% of patients [12–16]. When injuries Syncope can be the premonitory sign of a serious occur, syncope is often suspected to be caused by cardiac problem including cardiac arrest. Generally, a serious, life-threatening, or cardiac cause, but syncope is benign and self-limited but it can mimic data conflict [16,17]. Sudden, unexpected loss of a cardiac arrest and even be its precursor. Several consciousness (sometimes referred to as “Stokes– causes for syncope, generally cardiac, are potenti- Adams” attacks) can have many causes. The cir- ally fatal. When syncope is caused by hemodynamic cumstances that surround the episode and absence collapse from critical aortic stenosis, ventricular of a warning prodrome cause most injuries. Injury tachycardia, AV block, dissecting aortic aneurysm, itself does not necessarily indicate a life-threaten- or pulmonary embolus, an aggressive evaluation ing, cardiac, or arrhythmic cause for syncope, and treatment regimen is needed to forestall death. although sudden collapse with injury has been A potentially lethal cause should always be sus- associated with an arrhythmic cause. While an pected, especially in elderly patients, or it will be arrhythmic cause is often suspected when serious missed [5,6]. While less common, even younger injury results from syncope, few compelling data individuals with syncope can be at risk of death [7]. support the need for a more aggressive approach to For this age group, the congenital long QT inter- evaluate or to treat syncope in injured patients. val syndrome, hypertrophic cardiomyopathy, right Minor injuries occur in 10–29%, fractures occur ventricular dysplasia, Brugada syndrome, polymor- in 5–7% (more severe in the elderly), and traffic phic ventricular tachycardia with associated short accidents in 1–5% of syncope patients [18,19]. or normal QT interval, congenital aortic stenosis, among other causes, must be considered. Even ap- Syncope is expensive. Up to one million patients parently healthy individuals can die suddenly after annually are evaluated for syncope in the USA, with a syncopal episode (consider the death of basketball 500,000 new cases each year. Approximately 3–5% star Reggie Lewis [8]). of emergency room visits are to evaluate syncope [14,20], emergency room visits leading to hospital Syncope can have a major impact on lifestyle. admission [13]. Between 1 and 6% of acute hospital Patients’ reactions to syncope can vary from com- admissions are for syncope. The cost to evaluate plete lack of recognition and concern, to fear and and treat syncope exceeds $750 million/year. The difficulty returning to previous level of activities cost for the average admission is more than $5500 with complete disability. Even if syncope is benign, [20] and hospitalization is helpful in only 10% of it can have a major impact on quality of life and patients admitted in whom the etiology was not may change lifestyle dramatically, independent of clear by the admitting history, physical exam- physicians’ concerns and recommendations. The ination, and electrocardiogram (ECG). The cost degree of functional impairment from syncope can expended to determine one syncope diagnosis in match that of other chronic diseases, including patients diagnosed in 1982 was $23,000 [20] after a rheumatoid arthritis, chronic back pain, or chronic mean hospital stay of 9.1 days. When vasodepressor obstructive lung disease [9]. Patients can have fear syncope is not recognized, evaluations can lead to of recurrence and excessive fear of dying. There tremendous expense [21]. The costs per diagnosis can be imposed limitations on driving and work can be as high as $78,000, depending on the tests (see Chapter 20). Restrictions can be self-imposed, performed and the diagnostic accuracy. The aver- imposed by the family, by the physician, or by legal age patient with syncope makes 10.2 visits/year to a constraints (see Chapter 21). Up to 76% of patients physician and sees an average of 3.2 specialists for will change some activities of daily living, 64% will the problem [22]. restrict their driving, and 39% will change their Approximately 10% of falls in the elderly are SMAC01 01/21/2005 09:57 AM Page 3 CHAPTER 1 Syncope: Overview and approach to management 3 caused by syncope [23]. Serious injury is more Forty to eighty-five percent of those who come frequent when syncope precedes the fall [24–30]. for evaluation of syncope will not have a recurrence Falls occur in 20% of the population over 65 years [38]. Isolated episodes are common: 90% will have old. The cost to treat falls in the elderly exceeds only one episode in 2 years, yet 54% with two $7 billion/year in the USA [23]. It is a common episodes have recurrence over the same time period cause for disability. [39]. The recurrence rate of syncope remains similar despite widely different suspected causes (severe cardiovascular disease or not) and despite Epidemiology apparently effective treatment [38]. The fact that The frequency of syncope and its associated mor- syncope is frequently an isolated occurrence can tality varies with age, gender, and cause. In one make it difficult to diagnose and difficult to assess large series, 60% of syncope patients were women the need for treatment (it may or may not recur). [14], but in the Framingham study more younger An apparent therapeutic effect of any intervention syncope patients were women while more elderly may instead be related to the sporadic nature of the syncope patients were men [24]. In the Framing- symptom and not to treatment of the underlying ham study, syncope had occurred in 3% of men and process [38,40,41]. An older report suggested that 3.5% of women, based on biannual examinations tonsillar enlargement caused tachycardia and syn- [24], with the highest frequency in the elderly. In cope [42]. Following tonsillectomy, syncope did the Framingham population, the annual incidence not recur. Therefore, tonsillectomy was assumed to of syncope for those over 75 years old was 6% and prevent recurrent syncope. While ludicrous, it is the prevalence of syncope in the elderly was 5.6%, important to recognize the similarity to modern compared with a low of 0.7% in the 35–44-year- thinking on this same topic. old male population [24]. The elderly are most Even without treatment, syncope can remain likely to have syncope, to be injured from syncope, dormant for a protracted period or “respond” to to seek medical advice, and to be admitted to a the apparent effect of the evaluation itself.
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