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The Lancet. Neurology Aug 2022Orthostatic hypotension is an unusually large decrease in blood pressure on standing that increases the risk of adverse outcomes even when asymptomatic. Improvements in... (Review)
Review
Orthostatic hypotension is an unusually large decrease in blood pressure on standing that increases the risk of adverse outcomes even when asymptomatic. Improvements in haemodynamic profiling with continuous blood pressure measurements have uncovered four major subtypes: initial orthostatic hypotension, delayed blood pressure recovery, classic orthostatic hypotension, and delayed orthostatic hypotension. Clinical presentations are varied and range from cognitive slowing with hypotensive unawareness or unexplained falls to classic presyncope and syncope. Establishing whether symptoms are due to orthostatic hypotension requires careful history taking, a thorough physical examination, and supine and upright blood pressure measurements. Management and prognosis vary according to the underlying cause, with the main distinction being whether orthostatic hypotension is neurogenic or non-neurogenic. Neurogenic orthostatic hypotension might be the earliest clinical manifestation of Parkinson's disease or related synucleinopathies, and often coincides with supine hypertension. The emerging variety of clinical presentations advocates a stepwise, individualised, and primarily non-pharmacological approach to the management of orthostatic hypotension. Such an approach could include the cessation of blood pressure lowering drugs, adoption of lifestyle measures (eg, counterpressure manoeuvres), and treatment with pharmacological agents in selected cases.
Topics: Antihypertensive Agents; Blood Pressure; Humans; Hypertension; Hypotension, Orthostatic; Syncope
PubMed: 35841911
DOI: 10.1016/S1474-4422(22)00169-7 -
Emergency Medicine Practice Jun 2021Syncope is the transient loss of consciousness and postural tone, with spontaneous recovery. It accounts for approximately 1% of all emergency department visits and $5.6... (Review)
Review
Syncope is the transient loss of consciousness and postural tone, with spontaneous recovery. It accounts for approximately 1% of all emergency department visits and $5.6 billion in healthcare costs annually. In a very small subset of patients, syncope may be a warning sign for serious outcomes or death, but identifying these patients is challenging, as the emergency clinician must distinguish between life-threatening causes and the more common, benign etiologies. Low-yield and expensive testing is often performed, even for benign presentations. Much research on syncope is observational, and clinical decision rules frequently perform poorly in validation studies. This issue reviews the clinical and diagnostic findings that are useful for safely and efficiently identifying patients presenting to the emergency department with syncope.
Topics: Diagnosis, Differential; Emergency Service, Hospital; Humans; Syncope
PubMed: 34008935
DOI: No ID Found -
American Family Physician Feb 2017Dizziness is a common yet imprecise symptom. It was traditionally divided into four categories based on the patient's history: vertigo, presyncope, disequilibrium, and...
Dizziness is a common yet imprecise symptom. It was traditionally divided into four categories based on the patient's history: vertigo, presyncope, disequilibrium, and light-headedness. However, the distinction between these symptoms is of limited clinical usefulness. Patients have difficulty describing the quality of their symptoms but can more consistently identify the timing and triggers. Episodic vertigo triggered by head motion may be due to benign paroxysmal positional vertigo. Vertigo with unilateral hearing loss suggests Meniere disease. Episodic vertigo not associated with any trigger may be a symptom of vestibular neuritis. Evaluation focuses on determining whether the etiology is peripheral or central. Peripheral etiologies are usually benign. Central etiologies often require urgent treatment. The HINTS (head-impulse, nystagmus, test of skew) examination can help distinguish peripheral from central etiologies. The physical examination includes orthostatic blood pressure measurement, a full cardiac and neurologic examination, assessment for nystagmus, and the Dix-Hallpike maneuver. Laboratory testing and imaging are not required and are usually not helpful. Benign paroxysmal positional vertigo can be treated with a canalith repositioning procedure (e.g., Epley maneuver). Treatment of Meniere disease includes salt restriction and diuretics. Symptoms of vestibular neuritis are relieved with vestibular suppressant medications and vestibular rehabilitation.
Topics: Benign Paroxysmal Positional Vertigo; Diagnosis, Differential; Dizziness; Humans; Meniere Disease; Migraine Disorders; Physical Examination; Postural Balance; Syncope; Vertebrobasilar Insufficiency; Vestibular Neuronitis
PubMed: 28145669
DOI: No ID Found -
Journal of the American College of... Nov 2019Syncope is a commonly encountered and challenging problem in medical practice. Presentations are variable, and the causal mechanism often remains elusive even after... (Comparative Study)
Comparative Study Review
Syncope is a commonly encountered and challenging problem in medical practice. Presentations are variable, and the causal mechanism often remains elusive even after extensive (and often expensive) evaluation. Clinical practice guidelines have been developed to help guide the multidisciplinary approach necessary to diagnose and manage the broad spectrum of patients presenting with syncope. The American College of Cardiology/American Heart Association, in collaboration with the Heart Rhythm Society, published its first syncope guidelines in 2017. The European Society of Cardiology released the fourth iteration of its syncope guidelines in 2018. This review highlights the differences and congruencies between the 2 sets of recommendations, their implications for clinical practice, the remaining gaps in understanding, and areas of future research.
Topics: American Heart Association; Humans; Practice Guidelines as Topic; Societies, Medical; Syncope; United States
PubMed: 31699282
DOI: 10.1016/j.jacc.2019.09.012 -
Kardiologia Polska 2021Syncope is a frequent event in the general population. Approximately 1%-2% of all emergency department admissions are due to syncope and at least one-third of all people... (Review)
Review
Syncope is a frequent event in the general population. Approximately 1%-2% of all emergency department admissions are due to syncope and at least one-third of all people experience fainting in their life. Although consequences of cardiac syncope are generally feared, non-cardiac syncope is much more common and may be associated with severe injuries and quality-of-life impairment, particularly in older adults. Various diagnostic and therapeutic strategies have been created and implemented over decades, leading to significant improvements in diagnostic accuracy and treatment effectiveness. In recent years, diagnosis and treatment have further evolved according to an innovative approach focused on the hemodynamic mechanism underlying syncope, based upon the assumption that knowledge of the syncope mechanism is a prerequisite for effective syncope prevention and treatment. Therefore, a new classification of syncope has been proposed, which defines two main syncope phenotypes with different predominant mechanisms: the hypotensive phenotype, where hypotension or vasodepression prevails, and the bradycardic phenotype, where cardioinhibition prevails. Identification of syncope phenotype - bradycardic or hypotensive/vasodepressive - represents the first step towards personalized management of syncope, characterized by customized interventions for prevention. The present review aims to illustrate these new developments in the diagnosis and therapy of non-cardiac syncope within a mechanism-based perspective. Diagnosis and therapy of bradycardic and hypotensive phenotypes are discussed, with a focus on recent evidence.
Topics: Aged; Bradycardia; Hemodynamics; Humans; Hypotension; Syncope; Tilt-Table Test
PubMed: 34668180
DOI: 10.33963/KP.a2021.0138 -
American Family Physician Mar 2017Syncope is an abrupt and transient loss of consciousness caused by cerebral hypoperfusion. It accounts for 1% to 1.5% of emergency department visits, resulting in high...
Syncope is an abrupt and transient loss of consciousness caused by cerebral hypoperfusion. It accounts for 1% to 1.5% of emergency department visits, resulting in high hospital admission rates and significant medical costs. Syncope is classified as neurally mediated, cardiac, and orthostatic hypotension. Neurally mediated syncope is the most common type and has a benign course, whereas cardiac syncope is associated with increased morbidity and mortality. Patients with presyncope have similar prognoses to those with syncope and should undergo a similar evaluation. A standardized approach to syncope evaluation reduces hospital admissions and medical costs, and increases diagnostic accuracy. The initial assessment for all patients presenting with syncope includes a detailed history, physical examination, and electrocardiography. The initial evaluation may diagnose up to 50% of patients and allows immediate short-term risk stratification. Laboratory testing and neuroimaging have a low diagnostic yield and should be ordered only if clinically indicated. Several comparable clinical decision rules can be used to assess the short-term risk of death and the need for hospital admission. Low-risk patients with a single episode of syncope can often be reassured with no further investigation. High-risk patients with cardiovascular or structural heart disease, history concerning for arrhythmia, abnormal electrocardiographic findings, or severe comorbidities should be admitted to the hospital for further evaluation. In cases of unexplained syncope, provocative testing and prolonged electrocardiographic monitoring strategies can be diagnostic. The treatment of neurally mediated and orthostatic hypotension syncope is largely supportive, although severe cases may require pharmacotherapy. Cardiac syncope may require cardiac device placement or ablation.
Topics: Diagnosis, Differential; Education, Medical, Continuing; Electrocardiography; Humans; Syncope
PubMed: 28290647
DOI: No ID Found -
Pediatric Emergency Care Sep 2020The aims of the study were to perform the first systematic review of pediatric syncope etiologies and to determine the most common diagnoses with credible intervals...
OBJECTIVES
The aims of the study were to perform the first systematic review of pediatric syncope etiologies and to determine the most common diagnoses with credible intervals (CredIs).
METHODS
Review was performed within Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and used Embase, Scopus, PubMed, and the Cochrane Controlled Trial databases. The following inclusion criteria for the articles were used: minimum of 10 patients, standard definition of syncope used, subjects who were 21 years or younger, and subjects who were either a consecutive retrospective group or a prospective group. No restrictions were made regarding language of the studies, but an English abstract was required. The following information was collected: purpose of the study, definition of syncope, number of patients, patient age range, inclusion/exclusion criteria, and etiologies of syncope.
RESULTS
Of the 500 articles initially identified, 11 studies met the inclusion criteria and were the basis for this review. Three thousand seven hundred patients were included, ranging in age from 3 months to 21 years. The most common etiologies identified were vasovagal (52.2%; 95% CredI, 50.6-53.9), postural orthostatic tachycardia syndrome (13.1%; 95% CredI, 12.1-14.2), and cardiac causes (4.0%; 95% CredI, 3.39-4.65). A total of 18.3% (95% CredI, 17.0-19.5) of patients were found to have syncope of unknown cause.
CONCLUSIONS
Syncope is a common pediatric complaint. Most cases seen are a result of benign causes, with only a small percentage because of serious medical conditions. In addition, most syncopal episodes in the pediatric population are diagnosed clinically or with minimally invasive testing, emphasizing the importance of a detailed history and physical examination.
Topics: Child; Diagnosis, Differential; Humans; Medical History Taking; Physical Examination; Syncope
PubMed: 32530839
DOI: 10.1097/PEC.0000000000002149 -
Emergency Medicine Journal : EMJ Feb 2019Syncope is a common reason for ED attendance and it presents a major management challenge with regard to the appropriate workup and disposition. Nearly 50% of patients...
Syncope is a common reason for ED attendance and it presents a major management challenge with regard to the appropriate workup and disposition. Nearly 50% of patients are admitted, and for many this is unnecessary; clinical decision rules have not proven to decrease unnecessary admissions. The European Society of Cardiology has recently developed guidance for managing syncope in the ED. This article highlights the key steps in evaluating syncope in the ED, factors involved in determining risk of a cardiac cause, and considerations for admission, observation or discharge.
Topics: Aged; Decision Support Systems, Clinical; Diagnosis, Differential; Emergency Service, Hospital; Guideline Adherence; Hospitalization; Humans; Male; Middle Aged; Risk Factors; Syncope
PubMed: 30470687
DOI: 10.1136/emermed-2018-207767 -
Current Opinion in Neurology Feb 2024This review considers recent observations on vestibular syncope in terms of clinical features, laboratory findings, and potential mechanisms. (Review)
Review
PURPOSE OF REVIEW
This review considers recent observations on vestibular syncope in terms of clinical features, laboratory findings, and potential mechanisms.
RECENT FINDINGS
Vestibular syncope, potentially associated with severe fall-related injuries, may develop multiple times in about one-third of patients. Meniere's disease and benign paroxysmal positional vertigo are the most common causes of vestibular syncope, but the underlying disorders remain elusive in 62% of cases with vestibular syncope. The postictal orthostatic blood pressure test exhibits a lower diagnostic yield. Vestibular function tests, such as cervical vestibular-evoked myogenic potentials and video head impulse tests, can reveal one or more abnormal findings, suggesting compensated or ongoing minor vestibular dysfunctions. The pathomechanism of syncope is assumed to be the erroneous interaction between the vestibulo-sympathetic reflex and the baroreflex that have different operating mechanisms and action latencies. The central vestibular system, which estimates gravity orientation and inertia motion may also play an important role in abnormal vestibulo-sympathetic reflex.
SUMMARY
Vestibular disorders elicit erroneous cardiovascular responses by providing false vestibular information. The results include vertigo-induced hypertension or hypotension, which can ultimately lead to syncope in susceptible patients.
Topics: Humans; Syncope; Vestibule, Labyrinth; Benign Paroxysmal Positional Vertigo; Hypertension
PubMed: 38193502
DOI: 10.1097/WCO.0000000000001226 -
Minerva Medica Apr 2022To date, there are no doubts about the evaluation of patients with syncope, while differential diagnoses between presyncope and nonspecific symptoms, generically...
To date, there are no doubts about the evaluation of patients with syncope, while differential diagnoses between presyncope and nonspecific symptoms, generically referred to as dizziness, are complex and not clearly standardized. This paper aims to highlight the most frequent vestibular diseases, which can mimic a presyncopal episode in adult and older patients. It should be noted that nonspecific symptoms may be caused by multiple conditions, and they can coexist in the same person, making diagnosis even more difficult. Due to nonspecific symptoms and diagnostic complexity, evaluation of patients with presyncope or dizziness should be multidisciplinary, involving the syncope expert and the audiologist, since the first evaluation of the patient in the Emergency Department.
Topics: Adult; Diagnosis, Differential; Dizziness; Emergency Service, Hospital; Humans; Syncope; Vertigo
PubMed: 34542954
DOI: 10.23736/S0026-4806.21.07808-3