Head up tilt test; HUT
-
video (BradfordHospitals)
-
detailed explanation of HUT at Cleveland Clin
-
Newcastle HUT protocols (paper)
vasovagal (neurocardiogenic) SYNCOPE (overview)
-
family practice notebook - concise
-
detailed article on SYNCOPE (emedicine)
2012 JACC: new concepts in assessment of syncope
2011 AAFP: syncope evaluation
2006 AHA guidelines on syncope evaluation
- syncope guidelines (Europe)
-- summary -
take home message (2pages) (
FULL detailed 40pp)
diagnosis:
from European guidelines 2009:
1. Syncope is a transient loss of consciousness (T-LOC) due to transient global
cerebral hypoperfusion characterized by
- rapid onset,
- short duration, and
- spontaneous complete recovery.
2. Syncope can be classified as
- neurally-mediated (reflex syncope),
- secondary to orthostatic hypotension or
- secondary to cardiac causes.
3. Reflex syncope traditionally refers to a heterogeneous group of conditions in which
cardiovascular reflexes that are normally useful in controlling the circulation become
intermittently inappropriate, in response to a trigger.
4. Orthostatic intolerance syndromes are a common cause of syncope in elderly
population, and are usually secondary to autonomic failure, to the use of vasodilator
drugs or to volume depletion.
5. Arrhythmias are the most common cause of cardiac syncope, but structural
cardiovascular disease can also cause syncope in some circumstances.
6. There is a bimodal distribution of patient age on presentation: in adolescents
and young adults a reflex mechanism is the most common and above the age of 65 a
cardiac cause or orthostatic hypotension should be suspected.
7. The initial evaluation after T-LOC consists of:
- a careful history,
- physical examination, including orthostatic blood pressure measurements
- and electrocardiogram (ECG).
- Based on these findings, simple additional examinations such as, carotid sinus
massage, echocardiogram, ECG monitoring or orthostatic challenge can be indicated.
8. The initial evaluation can define the cause of syncope in 23-50% of patients and should
answer three key questions:
- Is it a true syncopal episode or not?
- Has the aetiological diagnosis been determined?
- Are there findings suggestive of a high risk of cardiovascular events or death?
9. Increased cardiac risk may be indicated by:
- severe structural or coronary heart disease,
- syncope on exertion or supine,
- palpitations at the time of syncope,
- family history of sudden cardiac death or non sustained ventricular tachycardia,
- abnormal ECG (see full text).
- Patients with high risk criteria require prompt hospitalization or intensive evaluation.
10. In low risk patients the degree of investigation depends on the frequency of
syncope and its impact on quality of life. In those low risk patients with T-LOC of
unknown origin and frequent recurrences, either a strategy consisting on early implant
of a loop recorder and wait for new T-LOC or to perform cardiac or neurally mediated
tests, can be followed.
11. The principal goals of treatment for patients with syncope are to prolong survival,
mainly by decreasing the risk of sudden cardiac death, limit physical injuries, and
prevent recurrences. The importance and priority of these different goals depend on
the cause of syncope.
12. Evaluation of T-LOC should ideally be performed by Syncope Management Units:
The main objectives of such units are to provide state-of-the-art guideline-based
assessment of symptomatic patients, in order to risk-stratify them, obtain an accurate
aetiological diagnosis and assess prognosis.
