SYNCOPE Křivan L. IKK FN Brno D:\FN%20Brno_modra_obdelnik.jpg syncope3 Syncope ØTransient loss of consciousness caused by reversible brain ischaemia. Patient gets conscious again without any electric, or pharmacological intervention. Syncope x Collaps •Syncope – loss of consciousness is due to brain hypoperfusion •Collapses - without unconsciousness (psychogenic, cataplexia, TIA) - with unconsciousness (hypoglycaemia, hypoxia, hyperventilation, seizures, intoxication) • faint Hospital admissions due to syncope •1 - 6% - all hospitalizations •3% - hosp. in the ICU •50% - out hospital diagnosis •92% - syncope •6% - non syncopal collapses •2% - syncope of unknown etiology M4600035-ECG_monitor-SPL ICU_Room Etiology of the syncope •Reflex (neurovegetative) 71% •Ortostatic hypotension 11% •Cardiac arrhythmias 12% •Structural heart disease 5% •Cerebrovascular 1% Reflex - neurovegetative •Vasovagal •Hypersenzitive carotic sinus •Caugh, micturial, deffecation, pain, brass instruments, weight lifting …) 6a00d83542d51e69e20133ed146686970b-800wi Mechanism of VVS •pooling of the blood in LE and GIT •decreased blood return to the RV - volumoreceptors •sympathetic activation + hypercontraction •mechanoreceptor irritaion •aferentation n.IX, X, C sympathetic fibres •centre of the reflex NTS •eferentation - vasodilatation, bradycardia syncope_medulla VVS •asthenic patients •increased dermografismus •standing, sitting •long standing in crowded places WATER_ACU0102-01-04-016A dermogr1t piirtopaukamointia Clasification VVS •Type I - mixed •Type II - cardioinhibitory •Type III - vasodepresoric convulsive%20syncopegif Head upright tilt test - HUT •passive phase - 40 min ortostasis ( 60st.) • farmacologic provocation •- 5 min horiz. position - isoproterenol ( 3microg/kg/min ) •- nitroglycerin ( l/2 - l tbl.) •- 20 min active ortostatic position NIBPM NIBPM HUT test 1 HUT 2 HUT Therapy of the VVS •regimen recommendation !!! •beta I selective BB •teophyllin •verapamil •disopyramid •scopolamin •cardiac pacing DDI hand%20with%20medication(1) Orthostatic hypotension •Sympathetic dysfunction -Primary: Shy-Drager, Parkinson -Secondary: DM, amyloidosis -Postexercise -Postprandial •Drug and alcohol induced (ACEI, diuretics) •Volume depletion (hemorrhagia, diarrhea) • Cardiac arrhytmias •SA node (SSSy) •AV node (AVB II.-III.st) •Supraventricular, ventricular tachycardias •Genentic channel disorders (LQT, Brugada) •Dysfunction PM, ICD •Proarrhythmia § 6693 Bradycardia Bradycardia AVNRT povrch SVT monomorfní a polymorfní KT NSVT TdP - torsade de pointes Torsades-de-points Torsades § PM Structural heart disease •Vavlvular disease •HOCMP •Atrial myxoma •Accute aortic dissection •Pericardial tamponade •Pulmonary embolism ao stenoza shxcema Ao stenosis myxom Myxoma HKMP HOCMP Cerebrovascular – steal phenomenon § subclaviansteal-thieme Cerebrovascular – steal phenomenon 6542529 645a61dd4e9298b66e4d7a5900ceb3 Investigagtion of syncope •History + physical examination •ECG, OT test, Carrotic sinus massage, Holter, ECHO, EEG, US carotic art. •HUT test, EP study, prolonged monitoring, psychiatric examination • •Single syncope of unknown etiology: •Stop further investigation in the right time and inform patient • Recurrent syncope of unknown etiology •Indication for an ILR (Implantable Loop Recorder) implantation http://www.saheart.com.au/img/services/sah-loop.jpg Picture of loop recorder Medtronic Reveal LINQ David Prutchi PhD www.implantable-device.com