SYNCOPESYNCOPE Rasim Enar, M.D. Professor of Cardiology İstanbul University – Cerrahpaşa Medical...
-
Upload
michelle-ball -
Category
Documents
-
view
222 -
download
5
Transcript of SYNCOPESYNCOPE Rasim Enar, M.D. Professor of Cardiology İstanbul University – Cerrahpaşa Medical...
SYNCOPESYNCOPESYNCOPESYNCOPE
Rasim Enar, M.D.Professor of Cardiology
İstanbul University – Cerrahpaşa Medical FacultyDepartment of Cardiology
Rasim Enar, M.D.Professor of Cardiology
İstanbul University – Cerrahpaşa Medical FacultyDepartment of Cardiology
Neuro- Cardiogenic SyncopeNeuro- Cardiogenic SyncopeNeuro- Cardiogenic SyncopeNeuro- Cardiogenic Syncope
Syncope - Definition
• Syncope; is a transient loss of conciousness and postural tone with spontaneous recovery
• Loss of consiousness is a result of , sudden and shorterm serebral hipoperfusion
• Restoration of conciousness or orientation after a syncopal episode is usually immediate, and does nor require electrical or chemical therapy for reversal
Neuro- Cardiogenic SyncopeNeuro- Cardiogenic SyncopeNeuro- Cardiogenic SyncopeNeuro- Cardiogenic Syncope
• 1- 6 % of all hospital admissions
• 3 % of Emergency Department visits
Prognosis – 1 year mortality risc
• Cardiogenic Syncope : 24 % • Non-Cardiogenic Syncope : 4 %
Neurocardiogenic SyncopeNeurocardiogenic Syncope
Prevelans
Etiology – Cardiac Causes
Anatomic causes Arrhythmic causesAortic stenosis
HOCM
Myocardial ischemia / infarction
Aortic dissection
Cardiac tamponade
Atrial myxoma
Severe pulmonary hypertension
Severe pulmonary emboli
Subclavian steal syndrome
Fallot tetralogy
Tachy-arrhythmias
- Supraventricular tachycardia
- Ventricular tachycardia
- Long-QT syndrome (primary /secondary)
- Brugada syndrome
Brady-arrythmia
- Atrioventricular block
- Pace-maker dysfunction
- ICD dysfunction
- Sinus node dysfunction / bradycardia
Sick Sinus Syndrome
Neurocardiogenic SyncopeNeurocardiogenic Syncope
“Primary Evaluation”
• Detailed clinical history obtained from the patient or the witness of the syncopal episode, about the period just before or after the episode will give clues about the etiology
• Ortostatic blood pressure measurements and careful physical examination including oscultation of cardiac murmurs and carotis bruits
• Standart ECG
Neurocardiogenic SyncopeNeurocardiogenic Syncope
Classification of syncope
• Neurocardiogenic syndromes e.g. vasovagal, carotid sinus hypersensitivity, situational
• Ortostatic
• Primary cause : cardiac arrhythmia – conduction disturbances
e.g. Bradycardia, Tachycardia, AV-Block, etc
• Structural cardiac or cardiopulmonary diseases
e.g. acute myocardial infarction, aortic dissection, acute pulmonary emboli, etc
Neurocardiogenic SyncopeNeurocardiogenic Syncope
Neuro- Cardiogenic SyncopeNeuro- Cardiogenic Syncope
Non-syncope seizures
• Syncope-like conditions, with loss or impairment of consciousness e.g. epileptic seizures, TIA, etc
• Syncope-like conditions, where the patient is conscious e.g. Psycogenic syncope (histerical, somatization disorders), etc
Neuro- Cardiogenic SyncopeNeuro- Cardiogenic Syncope
Clinical features associated with non-syncope seizure
• Post-seizure >5 min confusion (epileptic seizure)
• Long lasting tonic-clonic movements with the onset of the seizure
(epileptic seizure)
• Frequent somatic complaints without accompanying organic heart disease
(psycogenic)
• Vertigo, dizartria, diplopia (Transient Ischemic Attack)
Diagnostic Criteria – Certain (I)
Vasovagal syncope; Syncope with typical prodromal symptoms which is provoked with fear, severe pain, emotional stress, catheter instrumentation, or after prolonged standing in hot enviorement
Situational syncope; Syncope produced with vagal stimuli, like diüresis, frequeny coughing, defecation or swollowing
Ortostatic syncope; Syncope or presyncope associated withg documented ortostatic hipotension (Sudden fall of SBP > 20 mmHg or < 90 mmHg)
Neuro- Cardiogenic SyncopeNeuro- Cardiogenic Syncope
Syncope secondary to cardiac ischemia; ECG documentation of acute ischemia or infarction
Syncope secondary to cardiac arrhythmia ; ECG documentation of
• Sinüs bradycardia (< 40 beat/min or repetitive sinoatrial block or sinus pause > 3 second)
• Atrioventriküler block (2nd degree Mobitz Type II or 3rd degree)• Alternating LBBB or RBBB• Rapid paroxismal supraventricular tachycardia or ventricular
tachtcardia• Pace-maker dysfunction associated with cardiac pause
Diagnostic Criteria – Certain (II)
Neuro- Cardiogenic SyncopeNeuro- Cardiogenic Syncope
June 2004
Diagnostic Criteria - Probable
Conditions related with CARDIAC syncope ;
• Supine• Post egzersize• Post palpitation• Known serious organic heart disease• ECG disturbances
- wide QRS complex (>0.12 sec)- AV conduction disturbances- Post-meal at 1 hour- Post egzersize - Following with new drug administration or
after change of the dose
Neuro- Cardiogenic SyncopeNeuro- Cardiogenic Syncope
Neuro - Cardiogenic SyncopeNeuro - Cardiogenic Syncope
Which patients should be hospitalised
• Syncope secondary to a cardiac pathology
• Syncope resulted with serious injury
• Frequent syncope attacks
Neuro- Cardiogenic SyncopeNeuro- Cardiogenic Syncope
Diagnostic Tests
• Carotid Sinus Massage
• Tilt Table Test
• Holter monitorörization
• Echocardiyography
• Egzersize Test
• External or Internal Loop Recorders
• Electrophysiologic Study (EPS)
• Cardiac Catheterisation and coronary anjiography
• Neurologic and pschchiatric evaluation
Neuro- Cardiogenic SyncopeNeuro- Cardiogenic Syncope
Syncope (unknown etiology)
Probable Diagnosis (10%)
Unclassified syncope (60%)
Definite Diagnosis (10%)
History, Physical Exam, ECG
EchocardiographySpesific tests Spesific treatment & F/U
Organic Heart Disease / Arrhythmia ? Vazovagal syncope ?
EPS Tilt Table Test
Diagnosis (+) Diagnosis (-) Diagnosis (+) Diagnosis (-)
Spesific tx & F/U Spesific tx & F/UHolter / Tilt TT Holter / Tilt TT
Neuro- Cardiogenic SyncopeNeuro- Cardiogenic Syncope
Olası
TEŞHİS (-)
OLASI (?)
SENKOP Hikaye,FM, EKG
TEŞHİS (+)
OLASI SENKOP
Azalmış Kalp Debisi (SĞV,SV çıkış yolu obstrüksdiyonu,Mİ.
Ekokardiyografi: Kardiyak katereizasyon, CPK-MB,gelişte, Akc görüntüleme, pulmoner anjiyo.
SSS hastalığı (TİA,subklavyan çalma, migren, nöbet olasılığı, fokal nörolojik bulgular.
EEG, Serebral CT, Serebral aklım çalışması, Anjiyografi.
Karotis-sinüs Senkopu
Karotis masajı
Pulmoner Emboli emboli
BİR EPİSOD:
Tilt-testi.
?Holter.
TEKRARLAYAN SENKOP:
Tilt-test Psikiyatrik
tetkik. Holter. Loop-
kaydedici.
Kalp hastalığı (+)
Holter mont.
EFÇ: (-).
Tilt-
testi
Kalp hastalığı (-) NEGATİF