Define syncope.
Presyncope (adjective): indicates
symptoms and signs that occur before
unconsciousness in syncope
Presyncope (noun): A state that resembles
the prodrome of syncope, but which is not
followed by LOC
Define syncope.
TLOC due to cerebral hypoperfusion,
characterized by
1. A rapid onset
2. Short duration, and
3. Spontaneous complete recovery.
Define total loss of consciousness (TLOC).
TLOC definition: a state of real or apparent LOC with
loss of awareness, characterized by:
1. amnesia for the period of unconsciousness
2. abnormal motor control
3. loss of responsiveness, and a short duration loss
of voluntary muscle tone
Which systolic blood pressures will cause syncope? (2)
A systolic BP of 50–60 mmHg at heart level,
i.e. 30–45 mmHg at brain level in the upright
position, will cause LOC.
Give 5 clinical features that suggest a diagnosis of reflex syncope.
- Long history of recurrent syncope, in particular
occurring before the age of 40 years - After unpleasant sight, sound, smell, or pain
- Prolonged standing
- During meal
- Being in crowded and/or hot places
- Autonomic activation before syncope: pallor, sweating,
and/or nausea/vomiting - With head rotation or pressure on carotid sinus (as in
tumours, shaving, tight collars) - Absence of heart disease
Give 5 clinical features that suggest a diagnosis of orthostatic hypotension syncope.
- While or after standing
- Prolonged standing
- Standing after exertion
- Post-prandial hypotension
- Temporal relationship with start or changes of
dosage of vasodepressive drugs or diuretics
leading to hypotension - Presence of autonomic neuropathy or
parkinsonism
Give 4 clinical features that suggest a diagnosis of cardiac syncope.
- During exertion or when supine
- Sudden onset palpitation immediately followed by syncope
- Family history of unexplained sudden death at young age
- Presence of structural heart disease or coronary artery disease
- ECG findings suggesting arrhythmic syncope
Mention 3 indications for the tilt test.
- Recurrent unexplained (or single serious) syncope in
absence of heart disease - Recurrent unexplained (or single serious) syncope in
absence of heart disease, after cardiac causes of syncope
have been excluded - Assessing recurrent pre-syncope (incl POTS)
- After an aetiology of syncope has been established, but
where demonstration of susceptibility to neurallymediated
syncope would alter the therapeutic approach - Differentiating syncope with myoclonic jerks from
epilepsy (also PNES and psychogenic pseudo-syncope) - Evaluating patients with recurrent unexplained ‘falls’
Name test you should do in syncope.
- FBC, U&E, CRP*, glucose
- 12-lead ECG
- Patients may need investigating for postural
hypotension
Which tests should you not do in syncope? (2)
– Troponin if no chest pain / ECG changes
– CT brain
When should patients with syncope be admitted? (5)
- Suspected or known significant heart disease
- ECG abnormalities suggesting an arrhythmia
- Syncope during exercise
- Syncope occurring in supine position…
- Syncope causing severe injury
- Family history of sudden death
- Sudden onset palpitations in the absence of heart disease
- Frequent recurrent episodes..?
- Old and needs ‘sorting out’
Which patients with syncope have a poor prognosis?
Structural heart disease (independent of the cause of syncope)
Which patients with syncope have a excellent prognosis? (3)
- Young, healthy, normal 12-lead ECG
- Neurally-mediated syncope
- Orthostatic hypotension
- Unexplained syncope after thorough evaluation
How is non-cardiac syncope treated? (5)
- Patient education
- General measures
- Reduce / stop exacerbating medication
- Medication for syncope
- Dual chamber PPM for certain patients
(rare)
