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American Family Physician Sep 2011Syncope is a transient and abrupt loss of consciousness with complete return to preexisting neurologic function. It is classified as neurally mediated (i.e., carotid... (Review)
Review
Syncope is a transient and abrupt loss of consciousness with complete return to preexisting neurologic function. It is classified as neurally mediated (i.e., carotid sinus hypersensitivity, situational, or vasovagal), cardiac, orthostatic, or neurogenic. Older adults are more likely to have orthostatic, carotid sinus hypersensitivity, or cardiac syncope, whereas younger adults are more likely to have vasovagal syncope. Common nonsyncopal syndromes with similar presentations include seizures, metabolic and psychogenic disorders, and acute intoxication. Patients presenting with syncope (other than neurally mediated and orthostatic syncope) are at increased risk of death from any cause. Useful clinical rules to assess the short-term risk of death and the need for immediate hospitalization include the San Francisco Syncope Rule and the Risk Stratification of Syncope in the Emergency Department rule. Guidelines suggest an algorithmic approach to the evaluation of syncope that begins with the history and physical examination. All patients presenting with syncope require electrocardiography, orthostatic vital signs, and QT interval monitoring. Patients with cardiovascular disease, abnormal electrocardiography, or family history of sudden death, and those presenting with unexplained syncope should be hospitalized for further diagnostic evaluation. Patients with neurally mediated or orthostatic syncope usually require no additional testing. In cases of unexplained syncope, further testing such as echocardiography, grade exercise testing, electrocardiographic monitoring, and electrophysiologic studies may be required. Although a subset of patients will have unexplained syncope despite undergoing a comprehensive evaluation, those with multiple episodes compared with an isolated event are more likely to have a serious underlying disorder.
Topics: Algorithms; Diagnosis, Differential; Heart Function Tests; Humans; Medical History Taking; Physical Examination; Risk Assessment; Risk Factors; Syncope
PubMed: 21916389
DOI: No ID Found -
World Neurosurgery May 2021The proclivity to atlantoaxial instability (AAI) has been widely reported for conditions such as rheumatoid arthritis and Down syndrome. Similarly, we have found a...
BACKGROUND
The proclivity to atlantoaxial instability (AAI) has been widely reported for conditions such as rheumatoid arthritis and Down syndrome. Similarly, we have found a higher than expected incidence of AAI in hereditary connective tissue disorders. We demonstrate a strong association of AAI with manifestations of dysautonomia, in particular syncope and lightheadedness, and make preliminary observations as to the salutary effect of surgical stabilization of the atlantoaxial motion segment.
METHODS
In an institutional review board-approved retrospective study, 20 subjects (16 women, 4 men) with hereditary connective tissue disorders had AAI diagnosed by computed tomography. Subjects underwent realignment (reduction), stabilization, and fusion of the C1-C2 motion segment. All subjects completed preoperative and postoperative questionnaires in which they were asked about performance, function, and autonomic symptoms, including lightheadedness, presyncope, and syncope.
RESULTS
All patients with AAI reported lightheadedness, and 15 had refractory syncope or presyncope despite maximal medical management and physical therapy. Postoperatively, subjects reported a statistically significant improvement in lightheadedness (P = 0.003), presyncope (P = 0.006), and syncope (P = 0.03), and in the frequency (P < 0.05) of other symptoms related to autonomic function, such as nausea, exercise intolerance, palpitations, tremors, heat intolerance, gastroesophageal reflux, and sleep apnea.
CONCLUSIONS
This study draws attention to the potential for AAI to present with syncope or presyncope that is refractory to medical management, and for surgical stabilization of AAI to lead to improvement of these and other autonomic symptoms.
Topics: Adolescent; Adult; Atlanto-Axial Joint; Female; Humans; Incidence; Joint Instability; Male; Middle Aged; Retrospective Studies; Spinal Diseases; Syncope; Tomography, X-Ray Computed; Young Adult
PubMed: 33540088
DOI: 10.1016/j.wneu.2021.01.084 -
BMJ (Clinical Research Ed.) May 1994
Topics: Humans; Medical History Taking; Syncope
PubMed: 8205013
DOI: 10.1136/bmj.308.6939.1251 -
Annals of Emergency Medicine Dec 2014There is limited evidence to guide the emergency department (ED) evaluation and management of syncope. The First International Workshop on Syncope Risk Stratification in...
STUDY OBJECTIVES
There is limited evidence to guide the emergency department (ED) evaluation and management of syncope. The First International Workshop on Syncope Risk Stratification in the Emergency Department identified key research questions and methodological standards essential to advancing the science of ED-based syncope research.
METHODS
We recruited a multinational panel of syncope experts. A preconference survey identified research priorities, which were refined during and after the conference through an iterative review process.
RESULTS
There were 31 participants from 7 countries who represented 10 clinical and methodological specialties. High-priority research recommendations were organized around a conceptual model of ED decisionmaking for syncope, and they address definition, cohort selection, risk stratification, and management.
CONCLUSION
We convened a multispecialty group of syncope experts to identify the most pressing knowledge gaps and defined a high-priority research agenda to improve the care of patients with syncope in the ED.
Topics: Biomedical Research; Emergency Medical Services; Humans; Syncope
PubMed: 24882667
DOI: 10.1016/j.annemergmed.2014.04.014 -
Danish Medical Journal Sep 2013The epidemiology and prognosis of ''fainting'' or syncope has puzzled physicians over the years. Is fainting dangerous? This is a question often asked by the... (Review)
Review
The epidemiology and prognosis of ''fainting'' or syncope has puzzled physicians over the years. Is fainting dangerous? This is a question often asked by the patient--and the answer is ''it depends on a lot of things''. The diverse pathophysiology of syncope and the underlying comorbidites of the patients play an essential role. In epidemiology these factors have major impact on the outcome of the patients. Until recently, even the definition of syncope differed from one study to another which has made literature reviews difficult. Traditionally the data on epidemiology of syncope has been taken from smaller studies from different clinical settings with wide differences in patient morbidity. Through the extensive Danish registries we examined the characteristics and prognosis of the patients hospitalized due to syncope in a nationwide study. The aims of the present thesis were to investigate: 1) the use, validity and accuracy of the ICD-10 diagnosis of syncope R55.9 in the National Patient Registry for the use of this diagnosis in the epidemiology of syncope, 2) diagnostics used and etiology of a random selection of patients who had a discharge diagnosis of R55.9, 3) the incidence, prevalence and cardiovascular factors associated with the risk of syncope, 4) the prognosis in healthy individuals discharged after syncope, and 5) the prognosis of patients after syncope and evaluation of the CHADS2 score as a tool for short- and long-term risk prediction. The first studies of the present thesis demonstrated that the ICD-10 discharge diagnosis could reliably identify a cohort of patients admitted for syncope and that the discharge code carried a high number of unexplained cases despite use of numerous tests. The last studies showed that syncope is a common cause for hospital contact in Denmark and that the risk of syncope is tightly associated with cardiovascular co-morbidities and use of pharmacotherapy. Furthermore in patients with no co-morbidities (or healthy individuals), syncope is a significant and independent prognostic factor of adverse cardiovascular outcome and death compared to the background population. Lastly, evaluation of the CHADS2 score, as a tool for risk stratification, showed that it provided additional prognostic information on short- and long-term cardiovascular mortality in syncope patients compared to controls.
Topics: Age Factors; Cardiovascular Diseases; Comorbidity; Denmark; Humans; Incidence; International Classification of Diseases; Prevalence; Prognosis; Registries; Risk Assessment; Severity of Illness Index; Sex Factors; Syncope
PubMed: 24001470
DOI: No ID Found -
Current Hypertension Reports Aug 2013Orthostatic hypotension is a condition commonly affecting the elderly and is often accompanied by disabling presyncopal symptoms, syncope and impaired quality of life.... (Review)
Review
Orthostatic hypotension is a condition commonly affecting the elderly and is often accompanied by disabling presyncopal symptoms, syncope and impaired quality of life. The pathophysiology of orthostatic hypotension is linked to abnormal blood pressure regulatory mechanisms and autonomic insufficiency. As part of its diagnostic evaluation, a comprehensive history and medical examination focused on detecting symptoms and physical findings of autonomic neuropathy should be performed. In individuals with substantial falls in blood pressure upon standing, autonomic function tests are recommended to detect impairment of autonomic reflexes. Treatment should always follow a stepwise approach with initial use of nonpharmacologic interventions including avoidance of hypotensive medications, high-salt diet and physical counter maneuvers. If these measures are not sufficient, medications such as fludrocortisone and midodrine can be added. The goals of treatment are to improve symptoms and to make the patient as ambulatory as possible instead of targeting arbitrary blood pressure values.
Topics: Aging; Blood Pressure; Blood Pressure Determination; Humans; Hypertension; Hypotension, Orthostatic; Syncope
PubMed: 23832761
DOI: 10.1007/s11906-013-0362-3 -
Journal of Cardiology Mar 2014Syncope is one of the most common reasons for emergency department and urgent care clinic visits. The management of syncope continues to be a challenging problem for... (Review)
Review
BACKGROUND
Syncope is one of the most common reasons for emergency department and urgent care clinic visits. The management of syncope continues to be a challenging problem for front-line providers inasmuch as there are a multitude of possible causes for syncope ranging from relatively benign conditions to potentially life-threatening ones. In any event, it is important to identify those syncope patients who are at immediate risk of life-threatening events; these individuals require prompt hospitalization and thorough evaluation. Conversely, it is equally important to avoid unnecessary hospitalization of low-risk patients since unneeded hospital care adds to the healthcare cost burden.
RESULTS
Historically, front-line providers have taken a conservative approach with admission rates as high as 30-50% among syncope patients. A number of studies evaluating both the short- and long-term risk of adverse events in patients with syncope have focused on development of risk-stratification guidelines to assist providers in making a confident and well-informed choice between hospitalization and out-patient referral. In this regard, a much needed consensus on optimal decision-making process has not been developed to date. However, knowledge from various available risk-stratification studies can be helpful.
CONCLUSION
This review summarizes the findings of various risk-stratification studies and points out key differences between them. While, the existing risk-stratification methods cannot replace critical assessment by an experienced physician, they do provide valuable guidance. In addition, the various risk-assessment schemes highlight the need for careful initial clinical assessment of syncope patients, selective testing, and being mindful of the short- and long-term risks.
Topics: Cardiovascular Diseases; Hospitalization; Humans; Practice Guidelines as Topic; Referral and Consultation; Risk; Risk Assessment; Syncope; Unnecessary Procedures
PubMed: 24405895
DOI: 10.1016/j.jjcc.2013.03.019 -
European Heart Journal May 2021Head-up tilt test (TT) has been used for >50 years to study heart rate/blood pressure adaptation to positional changes, to model responses to haemorrhage, to assess...
Head-up tilt test (TT) has been used for >50 years to study heart rate/blood pressure adaptation to positional changes, to model responses to haemorrhage, to assess orthostatic hypotension, and to evaluate haemodynamic and neuroendocrine responses in congestive heart failure, autonomic dysfunction, and hypertension. During these studies, some subjects experienced syncope due to vasovagal reflex. As a result, tilt testing was incorporated into clinical assessment of syncope when the origin was unknown. Subsequently, clinical experience supports the diagnostic value of TT. This is highlighted in evidence-based professional practice guidelines, which provide advice for TT methodology and interpretation, while concurrently identifying its limitations. Thus, TT remains a valuable clinical asset, one that has added importantly to the appreciation of pathophysiology of syncope/collapse and, thereby, has improved care of syncopal patients.
Topics: Autonomic Nervous System Diseases; Heart Rate; Humans; Hypotension, Orthostatic; Syncope; Tilt-Table Test
PubMed: 33624801
DOI: 10.1093/eurheartj/ehab084 -
Epilepsia Dec 2012Clinicians who diagnose and manage epilepsy frequently encounter diagnoses of a nonneurological nature, particularly when assessing patients with transient loss of...
Clinicians who diagnose and manage epilepsy frequently encounter diagnoses of a nonneurological nature, particularly when assessing patients with transient loss of consciousness (T-LOC). Among these, and perhaps the most important, is cardiac syncope. As a group, patients with cardiac syncope have the highest likelihood of subsequent sudden death, and yet, unlike sudden unexpected death in epilepsy (SUDEP) for example, it is the norm for these tragic occurrences to be both easily predictable and preventable. In the 12 months following initial presentation with cardiac syncope, sudden death has been found to be 6 times more common than in those with noncardiac syncope (N Engl J Med 309, 1983, 197). In short, for every patient seen with T-LOC, two fundamental aims of the consultation are to assess the likelihood of cardiac syncope as the cause, and to estimate the risk of future sudden death for the individual. This article aims to outline for the noncardiologist how to recognize cardiac syncope, how to tell it apart from more benign cardiovascular forms of syncope as well as from seizures and epilepsy, and what can be done to predict and prevent sudden death in these patients. This is achieved through the assessment triad of a clinical history and examination, risk stratification, and 12-lead electrocardiography (ECG).
Topics: Death, Sudden; Epilepsy; Heart Diseases; Humans; Risk Factors; Syncope
PubMed: 23153208
DOI: 10.1111/j.1528-1167.2012.03713.x -
Clinical Cardiology Oct 1989The records of 483 patients admitted to the emergency room because of syncope were reviewed. Forty-one patients were found to have drug-related syncope. Thirty-nine...
The records of 483 patients admitted to the emergency room because of syncope were reviewed. Forty-one patients were found to have drug-related syncope. Thirty-nine experienced syncope related to drugs administered for cardiovascular disease. The most frequently associated diseases were anginal syndrome (22 patients), hypertension (13 patients), and a history of myocardial infarction (6 patients). Thirty-eight patients experienced symptomatic orthostatic hypotension following drug taking (nitrates in 19 patients, beta blockers in 10 patients, nifedipine in 3 patients, prazosin and quinidine in 2 patients each, methyldopa and verapamil in 1 patient each). One patient developed complete heart block as a result of digoxin intoxication. Two patients developed the characteristic picture of anaphylactic reaction (1 with ampicillin, 1 with dipyrone). During one-year follow-up, without the offending medications, no further syncopal episodes were reported by these patients. We conclude that drug-related syncope was more common among our patients with syncope than had been reported previously. It is suggested that drug-related syncope should be taken into consideration in any patient with syncope who is treated by any of the above-mentioned drugs.
Topics: Adult; Aged; Aged, 80 and over; Cardiovascular Agents; Cardiovascular Diseases; Diagnosis, Differential; Female; Humans; Male; Medical History Taking; Middle Aged; Retrospective Studies; Syncope
PubMed: 2805462
DOI: 10.1002/clc.4960121006