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Syncope
AM Report6/25/10
Nicole Wilde
SyncopeCause
Not Obvious Neurally Mediated (vasovagal) 58% Cardiac Disease (arrhythmias) 23% Neurologic or Psychiatric disease 1% Unexplained 18% (41% in other studies) Syncope vs Fall vs TIA, etc…
History
Number of episodes Associated Symptoms Prodrome (Auras) Sudden Onset Position Preceding Events Duration of Symptoms Medications and PMH
Physical
Abnormal Vital SignsOrthostatics Irregular HRHeart Sounds
Neurological abnormalities Positive stool guiac
Orthostatics
ECG
Sinus Bradycardia <40 BPM or sinus pause >3 sec
Mobitz II second or third degree AV block Alternating Left and Right BBB VT or rapid paroxysmal SVT Pacemaker malfunction with pauses
Hospitalizations
Suspected or known cardiac disease ECG abnormalities arrhythmia Syncope during exercise Syncope causing severe injury Family History of Sudden Death Sudden onset of palpitations, syncope in supine
position, frequent episodes 2004 ESC Syncope Guidelines
Work Up of Syncope
Echo Severe AS, Atrial Myxoma Exercise Testing CAD, Heart Block,
Autonomic Failure ECG, Telemetry, Holter Monitoring, External
Event Recorder, Implantable Loop Recorder Carotid Sinus Massage Upright Tilt Table Test EEG and Psychiatric Evaluations EP Studies Conduction system disease
Summary
Majority of patients without heart disease with rare episodes neurally mediated syncope and confirmation with tests are not needed
Recurrent episodes carotid massage, tilt testing, and prolonged ECG
Neurological referral when autonomic failure or cerebrovascular steal suspected
EEG or carotid doppler US not recommended when syncope most likely cause for LOC
Brugada Syndrome
Sudden Cardiac Arrest ECG with pseudo RBBB and ST elevation
in leads V1-V3 Coved and saddle back appearance Provoking factors: fever, drugs, electrolyte
abnormalities, etc.
Brugada Syndrome
Brugada Syndrome
Autosomal Dominant, variable expression Mutations in SCN5A cardiac sodium
channel gene Sodium Channel blockers expose ECG
changes ICD placement