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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 -
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 -
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 -
Respiratory Medicine Feb 2014Loss of consciousness following cough was first described in 1876 as "laryngeal vertigo" Since then, several hundred cases of what is now most commonly termed cough... (Review)
Review
Loss of consciousness following cough was first described in 1876 as "laryngeal vertigo" Since then, several hundred cases of what is now most commonly termed cough syncope have been reported, often in association with various medical conditions. Some early authors assumed this entity to be a form of epilepsy, but by the mid-20th century, general consensus reflected that post-tussive syncope was a consequence of markedly elevated intrathoracic pressures induced by coughing. A typical profile of the cough syncope patient emerging from the literature is that of a middle-aged, large-framed or overweight male with obstructive airways disease. Presumably, such an individual would be more likely to generate the extremely high intrathoracic pressures associated with cough-induced fainting. The precise mechanism of cough syncope remains a matter of debate. Theories proposed include various consequences of the marked elevation of intrathoracic pressures induced by coughing: diminished cardiac output causing decreased systemic blood pressure and, consequently, cerebral hypoperfusion; increased cerebrospinal fluid (CSF) pressure causing increased extravascular pressure around cranial vessels, resulting in diminished brain perfusion; or, a cerebral concussion-like effect from a rapid rise in CSF pressure. More recent mechanistic studies suggest a neurally mediated reflex vasodepressor-bradycardia response to cough. Since loss of consciousness is a direct and immediate result of cough, elimination of cough will eliminate the resultant syncopal episodes. Thus, the approach to the patient with cough syncope requires thorough evaluation and treatment of potential underlying causes of cough, as summarized in several recently published cough management guidelines.
Topics: Acute Disease; Chronic Disease; Cough; Female; Humans; Male; Syncope
PubMed: 24238768
DOI: 10.1016/j.rmed.2013.10.020 -
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 -
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 -
Cleveland Clinic Journal of Medicine Dec 2014There are three major types of syncope: neurally mediated (the most common), orthostatic hypotensive, and cardiac (the most worrisome). Several studies have shown a... (Review)
Review
There are three major types of syncope: neurally mediated (the most common), orthostatic hypotensive, and cardiac (the most worrisome). Several studies have shown a normal long-term survival rate in patients with syncope who have no structural heart disease, which is the most important predictor of death and ventricular arrhythmia. The workup of unexplained syncope depends on the presence or absence of heart disease: electrophysiologic study if the patient has heart disease, tilt-table testing in those without heart disease, and prolonged rhythm monitoring in both cases if syncope remains unexplained.
Topics: Heart Diseases; Humans; Hypotension, Orthostatic; Syncope; Syncope, Vasovagal
PubMed: 25452354
DOI: 10.3949/ccjm.81a.13152 -
Lakartidningen Feb 2019Syncope is the chief complaint in 1-2 percent of emergency department visits. Syncope belongs to the broader category transient loss of consciousness (TLOC), defined as... (Review)
Review
Syncope is the chief complaint in 1-2 percent of emergency department visits. Syncope belongs to the broader category transient loss of consciousness (TLOC), defined as a short loss of consciousness with loss of awareness and responsiveness, and with subsequent amnesia for the event. Syncope is defined as TLOC due to cerebral hypoperfusion, with rapid onset and spontaneous complete recovery. The main categories of syncope are reflex syncope, orthostatic hypotension, and cardiac syncope. The 2018 guidelines by the European Society of Cardiology emphasizes the process of risk stratification in the initial management of suspected syncope. Risk stratification serves to separate the patients with likely orthostatic and reflex syncope with good prognosis from the patients with likely cardiac syncope and high short-term risk of an adverse outcome. It determines the appropriate next level of care. Further evaluation should be based on clinical suspicion and frequency of symptoms.
Topics: Cardiology; Critical Pathways; Diagnosis, Differential; Disease Management; Europe; Humans; Hypotension, Orthostatic; Practice Guidelines as Topic; Risk Assessment; Societies, Medical; Syncope; Syncope, Vasovagal
PubMed: 31192373
DOI: No ID Found -
Pacing and Clinical Electrophysiology :... Oct 2020Recent studies have described several cardiovascular manifestations of COVID-19 including myocardial ischemia, myocarditis, thromboembolism, and malignant arrhythmias....
INTRODUCTION
Recent studies have described several cardiovascular manifestations of COVID-19 including myocardial ischemia, myocarditis, thromboembolism, and malignant arrhythmias. However, to our knowledge, syncope in COVID-19 patients has not been systematically evaluated. We sought to characterize syncope and/or presyncope in COVID-19.
METHODS
This is a retrospective analysis of consecutive patients hospitalized with laboratory-confirmed COVID-19 with either syncope or presyncope. This "study" group (n = 37) was compared with an age and gender-matched cohort of patients without syncope ("control") (n = 40). Syncope was attributed to various categories. We compared telemetry data, treatments received, and clinical outcomes between the two groups.
RESULTS
Among 1000 COVID-19 patients admitted to the Mount Sinai Hospital, the incidence of syncope/presyncope was 3.7%. The median age of the entire cohort was 69 years (range 26-89+ years) and 55% were men. Major comorbidities included hypertension, diabetes, and coronary artery disease. Syncopal episodes were categorized as (a) unspecified in 59.4% patients, (b) neurocardiogenic in 15.6% patients, (c) hypotensive in 12.5% patients, and (d) cardiopulmonary in 3.1% patients with fall versus syncope and seizure versus syncope in 2 of 32 (6.3%) and 1 of 33 (3.1%) patients, respectively. Compared with the "control" group, there were no significant differences in both admission and peak blood levels of d-dimer, troponin-I, and CRP in the "study" group. Additionally, there were no differences in arrhythmias or death between both groups.
CONCLUSIONS
Syncope/presyncope in patients hospitalized with COVID-19 is uncommon and is infrequently associated with a cardiac etiology or associated with adverse outcomes compared to those who do not present with these symptoms.
Topics: Adult; Aged; Aged, 80 and over; Betacoronavirus; COVID-19; Comorbidity; Coronavirus Infections; Female; Hospitalization; Humans; Incidence; Male; Middle Aged; New York City; Pandemics; Pneumonia, Viral; Retrospective Studies; SARS-CoV-2; Syncope; Telemetry
PubMed: 32840325
DOI: 10.1111/pace.14047