Cardiovascular Medicine Book

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Syncope

Aka: Syncope, Near-syncope, Presyncope
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  1. See Also
    1. Vasovagal Syncope
    2. Cardioinhibitory Syncope
    3. Vasodepressor Syncope
    4. San Francisco Syncope Rule
  2. Definition
    1. Rapid onset of transient loss of consciousness
    2. May be associated with a fall
    3. Resolves spontaneously and quickly
  3. Background
    1. Up to one third of Syncope cases are idiopathic
    2. Common diagnosis
      1. Occurs in up to 50% of adults, and 75% over age 75
      2. Accounts for up to 3% of ER visits, 6% of admissions
  4. Pathophysiology
    1. Decreased cerebral perfusion (usually on standing)
  5. Causes: Non-Cardiac Causes (57%)
    1. Reflex Mediated Syncope (no cardiovascular risk)
      1. Vasovagal Syncope (Vasodepressor Syncope)
      2. Situational Syncope
        1. Micturition Syncope or with Defecation
        2. Cough Syncope (or sneezing)
        3. Valsalva (brass instrument playing, weight lifting)
        4. Hyperventilation
      3. Carotid Sinus Syncope
      4. Glossopharyngeal neuralgia (uncommon)
        1. Syncope occurs with swallowing, talking, sneezing
      5. Trigeminal Neuralgia
    2. Medication-related Syncope
      1. Antihypertensive Medications (e.g. Beta Blocker)
      2. Ophthalmic Beta Blockers
      3. Antianginal medications (e.g. Nitroglycerin)
      4. Digitalis
        1. Atrioventricular Block
        2. Ventricular Tachycardia
      5. Antiarrhythmic medications (esp. Type Ia)
      6. Diuretics
        1. Hypokalemia
        2. Hypomagnesemia
        3. Hypovolemia
      7. Adriamycin
      8. Phenothiazines
      9. Tricyclic Antidepressants
    3. Recreational drug use
      1. Alcohol
      2. Ecstasy (MDMA)
      3. Methamphetamine
    4. Orthostatic Syncope (2-24%)
      1. See Orthostatic Hypotension
    5. Neurologic Causes (9% of causes)
      1. Transient Ischemic Attacks: 1-7%
      2. Seizure disorder: 2%
  6. Causes: Cardiovascular (10-30% of causes)
    1. Arrhythmia
      1. Ventricular Tachycardia
      2. Sick Sinus Syndrome
      3. Supraventricular Tachycardia
      4. Atrioventricular Block (second or third degree)
      5. Pacemaker malfunction
    2. Aortic Stenosis
    3. Mitral Stenosis
    4. Myocardial Infarction
    5. Aortic Dissection
    6. Pulmonary Embolism
    7. Pulmonary Hypertension
    8. Subclavian Steal Syndrome
    9. Hypertrophic Cardiomyopathy
    10. Atrial myxoma
  7. History: Predisposing Conditions
    1. Family History of Sudden Cardiac Death (e.g. SADS)
    2. Diabetes Mellitus (Hypoglycemia)
    3. Parkinson's Disease (Orthostatic Hypotension)
    4. Seizure Disorder
  8. History: Preceeding or provocative event
    1. Prolonged standing (e.g. Vasovagal Syncope)
    2. Immediately on standing (Orthostatic Hypotension)
    3. With exertion (Cardiomyopathy, CAD, Valve stenosis)
    4. After exertion in an athlete (Vasovagal Syncope)
    5. Valsalva (cough, swallowing, urinating or stooling)
      1. Reflex-mediated Syncope
    6. Neck rotation or pressure (e.g. tight collar)
      1. Carotid Sinus Hypersensitivity
    7. Use of arms (Subclavian Steal Syndrome)
    8. Stressful event (Vasovagal Syncope)
  9. History: Associated symptoms during event
    1. Nausea, chills and sweats (Vasovagal Syncope)
    2. Aura (Migraine Headache, Seizure Disorder)
    3. Slumping (Coronary Artery Disease, arrhythmia)
    4. Kneeling (Orthostatic Hypotension)
    5. Brief loss of consciousness (arrhythmia)
    6. Loss of consciousness >5 minutes
      1. Neurologic, metabolic, or infectious cause
    7. Tonic-clonic movements
      1. Movements occur before fall (Seizure disorder)
      2. Movements occur after fall (Vasovagal Syncope)
    8. Chest Pain (CAD, PE, Aortic Dissection)
    9. Palpitations (Arrhythmia)
    10. Incontinence of urine or stool (Seizure)
  10. Signs
    1. General
      1. Pallor (Orthostatic Hypotension due to Anemia)
      2. Tongue bitten (Seizure)
    2. Cardiovascular examination
      1. Carotid Bruits
      2. Heart Murmur
      3. Asymmetric pulses
      4. Carotid massage
        1. Avoid in Cerebrovascular Disease or Carotid Bruit!
    3. Neurologic Exam
      1. Post-event Confusion (Seizure Disorder)
      2. Focal neurologic deficit
  11. Differential Diagnosis
    1. Vertigo (no loss of consciousness)
    2. Drop Attacks (No loss of consciousness, no aura)
    3. Seizure
  12. Labs and diagnostic testing: Initial evaluation
    1. Serum electrolytes including Glucose
    2. Hemoglobin or Hematocrit
    3. Electrocardiogram
      1. See Electrocardiogram in Syncope
    4. Chest XRay
    5. Brain Natriuretic Peptide (BNP)
      1. BNP > 40 pg/ml strongly suggests cardiac cause
      2. Test Sensitivity: 82%
      3. Test Specificity: 92%
      4. Tanimoto (2004) Am J Cardiol 93:228-30
    6. Additional tests to strongly consider
      1. Serial Troponin I and inpatient telemetry monitoring
      2. Cardiac stress testing
      3. Event Monitor or Holter Monitor
      4. Echocardiogram
  13. Reassuring findings suggestive of neurally-mediated cause
    1. No cardiac history
    2. Chronic history of Syncope
    3. Triggered by specific stimulus
      1. Noxious smell, sound, sight or pain
      2. Prolonged standing, crowded place, heat
      3. Nausea or Vomiting
      4. Post-meal
      5. Rotation of head or tight collar, shaving
      6. Post-exertion
  14. Hospitalization Indications
    1. Syncopal episode occurring during Exercise
    2. Family History of sudden death
    3. Severe Orthostatic Hypotension
    4. Suspected underlying serious cause
      1. Coronary Artery Disease
      2. Cardiac arrhythmia
      3. Cerbebrovascular accident
    5. References
      1. Brignole (2001) Eur Heart 22:1256-306
  15. Prognosis
    1. See San Francisco Syncope Rule
      1. Predicts short-term risk of serious outcome
    2. Mortality 10% within 6 months of cardiovascular Syncope
      1. Soteriades (2002) N Engl J Med 347:878-85
  16. References
    1. Kapoor (2000) N Engl J Med 343:1856-62
    2. Brignole (2001) Eur Heart J 22:1256-306
    3. Miller (2005) Am Fam Physician 72:1492-500

Syncope (C0039070)

Definition (NCI) A spontaneous loss of consciousness caused by insufficient blood supply to the brain.
Definition (NCI) A disorder characterized by spontaneous loss of consciousness caused by insufficient blood supply to the brain.
Definition (NCI) Extremely weak; threatened with syncope.
Definition (MEDLINEPLUS)

If you've ever fainted, you are not alone - at least one third of people faint sometime in their lives. Fainting is a temporary loss of consciousness. You lose muscle control at the same time, and may fall down. Most people recover quickly and completely.

Fainting usually happens when your blood pressure drops suddenly, causing a decrease in blood flow to your brain. This is more common in older people. Some causes of fainting include

  • Heat or dehydration
  • Emotional distress
  • Standing up too quickly
  • Certain medicines
  • Drop in blood sugar
  • Heart problems

Fainting is usually nothing to worry about, but it can sometimes be a sign of a serious problem. If you faint, it's important to see your health care provider and find out why it happened.

Definition (MSH) A transient loss of consciousness and postural tone caused by diminished blood flow to the brain (i.e., BRAIN ISCHEMIA). Presyncope refers to the sensation of lightheadedness and loss of strength that precedes a syncopal event or accompanies an incomplete syncope. (From Adams et al., Principles of Neurology, 6th ed, pp367-9)
Definition (CSP) fainting due to a sudden fall of blood pressure below the level required to maintain oxygenation of brain tissue.
Definition (NCI) Extremely weak; threatened with syncope.
Concepts Sign or Symptom (T184)
MSH D013575
ICD9 780.2
ICD10 R55
SnomedCT 206727002, 206725005, 206731008, 158137001, 158135009, 271211004, 158133002, 271594007, 309585006, 272030005, 29423006, 271785004, 139532000, 162263008
English Faintness, Fainting, Syncope, Syncopes, FAINTING EPISODES, COLLAPSE FLEETING, COLLAPSE TRANSIENT, FAINTNESS, FALLING OUT, Fainted, PASSED OUT, SWOONING, SYNCOPE, Syncope, NOS, Syncope and collapse NOS, [D]Syncope, [D]Syncope and collapse, [D]Syncope and collapse NOS, A faint, Passed out, [D]Fainting (context-dependent category), [D]Syncope and collapse (context-dependent category), [D]Syncope and collapse NOS (context-dependent category), [D]Fainting, fainting (syncope), syncope, fainting, fainting (symptom), [D]Syncope and collapse NOS (situation), [D]: [fainting] or [collapse] (situation), [D]: [fainting] or [collapse] (disorder), [D]Syncope and collapse (situation), Syncopal attack, Falling out, Swooning, [D]Fainting (situation), Faint, FAINT, FAINTING, Syncope [Disease/Finding], attacks syncopal, disorders syncope, fainting episodes, falls out, Attack(s);fainting, collapse syncope, faint, fainted, faints, syncope attack, out pass, pass out, attacks fainting, out passed, syncopes, fainting/syncope, Swoon, faintings, syncope fainting, faintness, swoons, out passes, swooning, passed out, syncope collapse, fainting syncope, Syncope and collapse, Syncope symptom, Syncope attack, Syncope (disorder), Syncope and collapse (disorder), Syncope symptom (disorder), Fainting/syncope, attack; syncope, attack; unconsciousness, collapse; general, fainting; fit, fit; fainting, general; collapse, loss of consciousness; attack, syncope; syncope, unconsciousness; attack, Faint symptom, Fainting (finding), Fainting [D], Syncope (finding), [D]: [fainting] or [collapse], Collapse fleeting, Collapse transient, fainting attacks, swoon
French SYNCOPE, Collapsus passager, Tendance lipothymique, Syncope et collapsus, Ivre mort, Evanouissements, Collapsus transitoire, Chutes fréquentes, Pâmoison, Lipothymie, COLLAPSUS TRANSITOIRE, DECES, ETAT SYNCOPAL, EVANOUISSEMENT, Evanouissement/syncope, PERTE DE CONNAISSANCE, Syncope, Évanouissement
Portuguese SINCOPE, DESMAIO, Síncope e colapso, Ataque de síncope, Colapso transitório, Esvaimento, Perda de consciência, Desmaiado, Colapso passageiro, COLAPSO TRANSITORIO, DEBILIDADE, DESFALECIMENTO, DESMAIADO, Desmaio/sincope, Desmaio, Síncope
Spanish DESVANECIMIENTO, SINCOPE, DESMAYO, Colapso transitorio, Desfallecimiento, Episodio sincopal, Síncope y colapso, Privación de sentido, Alferecía, Pérdida de conocimiento, Desvanecimiento, Colapso fugaz, [D]desvanecimiento (categoría dependiente del contexto), [D]síncope y colapso (categoría dependiente del contexto), [D]síncope y colapso SAI (categoría dependiente del contexto), Faint symptom, [D]Syncope and collapse NOS, [D]Syncope and collapse, Collapse [D], Fainting [D], Syncope symptom, [D]: [fainting] or [collapse], CAIDA, COLAPSO TRANSITORIO, DESFALLECIMIENTO, Desmayo/sincope, [D]síncope y colapso SAI, [D]síncope y colapso SAI (situación), [D]desvanecimiento (situación), [D]desvanecimiento, [D]síncope y colapso (situación), [D]síncope y colapso, síncope (trastorno), síncope - síntoma (trastorno), síncope - síntoma, síncope y colapso (trastorno), síncope y colapso, síncope, desmayo, desvanecimiento (hallazgo), desvanecimiento, síncope (hallazgo), Sincope, Desmayo, Síncope
German SYNKOPE, ohnmaechtig, Kollaps fluechtig, synkopale Attacke, schwach, bewusstlos werden, Synkope und Kollaps, Kollaps voruebergehend, schwummrig, ohnmaechtig werden, Ohnmachtsanfall, BEWUSSTLOSIGKEIT FLUECHTIG, KOLLAPS KURZDAUERND, Kollaps/Ohnmacht/Synkope, OHNMACHT, OHNMAECHTIG WERDEN, SCHWAECHEANFALL, Ohnmacht, Synkope
Dutch kortdurende collaps, flauwte, flauw, flauwteaanval, flauwvallen, voorbijgaande collaps, syncope en collaps, uitvallen, flauwgevallen, aanval van syncope, Flauwvallen/syncope, aanval; bewusteloosheid, aanval; syncope, algemeen; collaps, bewusteloosheid; aanval, bewustzijnsverlies; aanval, collaps; algemeen, flauwvallen; toeval, syncope; aanval, toeval; flauwvallen, Syncope en collaps, syncope, Collaps, Flauwvallen, Syncope
Italian Attacco sincopale, Sfaldarsi, Sincope e collasso, Collasso transitorio, Malore, Svenuto, Svenimento/sincope, Svenimento, Sincope
Japanese 卒倒, 一過性虚脱, 浮動性めまい感, 失神発作, ｼｯｼﾝ, ｲｯｶｾｲｷｮﾀﾞﾂ, ｿｯﾄｳ, ｼｯｼﾝﾎｯｻ, ﾌﾄﾞｳｾｲﾒﾏｲｶﾝ, ｷｾﾞﾂ, 脳貧血, 気絶, 失神
Swedish Svimning, SVIMNING
Czech synkopa, Tranzientní kolaps, Synkopický záchvat, Omdlívající, Mdloba, Synkopa a kolaps, Synkopa, Výpadek, Upadnout do bezvědomí, Pocit závratě
Finnish Pyörtyminen, PYORTYMINEN
Russian SINKOPE, OBMOROK, OBMOROK POSTURAL'NYI, POTERIA SOZNANIIA, PREDOBMOROCHNOE SOSTOIANIE, ОБМОРОК, ПОТЕРЯ СОЗНАНИЯ, ОБМОРОК ПОСТУРАЛЬНЫЙ, ПРЕДОБМОРОЧНОЕ СОСТОЯНИЕ, СИНКОПЕ
Norwegian BESVIMELSE/-TENDENS r55
Danish Kortvarigt bevidsthedstab/synkope
Hungarian ajulas/eszmeletvesztes, Ájult, Syncopés roham, Syncope és collapsus, Átmeneti collapsus, Ájulásérzés, Múló collapsus, Syncope, Ájulás, Elájulás, Összeesés
Korean 실신 및 허탈
Croatian SINKOPA
Basque ZORABIOA (SINKOPEA),KONORTE GALTZEA
Hebrew hitalfut
Polish Zapaść, Omdlenie
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Presyncope (C0700200)

Definition (NCI) An episode of lightheadedness and dizziness which may precede an episode of syncope.
Definition (NCI) A disorder characterized by an episode of lightheadedness and dizziness which may precede an episode of syncope.
Concepts Sign or Symptom (T184)
MSH D013575
SnomedCT 427461000
English NEAR SYNCOPE, PRE-SYNCOPE, PRESYNCOPE, Pre-syncope, Near syncope (disorder), Near syncope, presyncope, Presyncopes, near syncope, pre-syncope, pre syncope, Presyncope
Dutch presyncope, bijna-syncope, Presyncope
French Syncope rattrapée, Malaise, Présyncope, LIPOTHYMIE
German Praesynkope, Beinahe-Synkope, Präsynkope, PRAE-SYNKOPE
Italian Semisincope, Pre-sincope
Portuguese Pré-síncope, Quase síncope, Pré-Síncope, PRE-SINCOPE
Spanish Estado presincopal, casi síncope (trastorno), casi síncope, Presíncope, Presincope, PRE-SINCOPE
Japanese 失神寸前の状態, ｼｯｼﾝｽﾝｾﾞﾝﾉｼﾞｮｳﾀｲ
Czech Presynkopa, Blízko synkopy
Hungarian Presyncope, Praesyncope
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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