Syncope diagnostic algorithm and management MUDr. Jakub Honěk MUDr. Martin Horváth Kardiologická klinika, 2.LF UK a FN Motol, Praha

The importance of appropriate diagnostics a managementu of syncopy Prognosis The importance of appropriate diagnostics a managementu of syncopy Soteriades et al. N Eng J Med, 2003.

Definition Loss of consciousness Syncope is a T-LOC due to transient global cerebral hypoperfusion characterized by rapid onset, short duration, and spontaneous complete recovery. T-LOC – wider term– all losses of consciousness independent of the pathophysiological cause Loss of consciousness Transient global hypoperfusion of brain - circulatory cause Sudden onset Short duration Spontaneous and full recovery ESC Guidelines for the diagnosis and management of syncope (version 2009): Moya et al. Eur Heart J, 2009.

Clasification of syncope Reflex syncope Vasovagal Situational Carotid sinus hypersensitivity Atypical forms Orthostatic hypotension Primary ANF Secondary ANF Iatrogenous Volume depletion Cardiac syncope Arrhythmia as a primary cause Structural heart disease

Initial workup Thorough history Physical examination circumstances preceding the syncope, prodromal symptoms, what hapenned during (bystanders) Personal/family history, sudden death?, medication, has it happened before? Physical examination Blood pressure lying down (5 mins) and standing (1st and 3rd min.) ECG

Key questions What it really a syncope? Has a diagnosis been made?+ Risk? High risk of cardiovascular event or sudden death?

Initial workup Suspected syncope Syncope Diagnosis Uncertain diagnosis High risk Early diagnostics and treatment Low risk, recurrent further workup Low risk, isolated event Diasnotics not indicated Nonsyncopal T-LOC Further workup, consultation of specialist, treatment

Risk stratificaion Structural heart disease CAD (previous MI), heart failure, aortic stenosis, HCM Clinical and ECG signs of arrhythmic etiology Syncope lying down, physical activity, palpitations Family history of sudden death Bifascicular blocade, nsVT, susp. SSS, preexcitation, ↑QTc, Brugada, susp. ARVC Age >40let + recurrent syncope (50% arrhytmia) Serious comorbidities Anemia, ionic imbalances

Further examination Diagnostic methods Carotid massage Pause > 3s, BP drop > 50 mmHg Uncertain cause in pts > 40-yrs Tilt test Reflex syncope – cardioinhibitory, vasodepressor and mixed reacions X orthostatic hypotension Suspected reflex syncope, high risk pts. without cardiac cause, susp. OH, difdg. falls, epilepsy, pseudosyncopies

Further examination Diagnostic methods ECG monitoration During hospiralization Suspected arrhythmic cause, high risk Holter ECG (24h, 48h, 7d) Recurrent syncopies/presyncopies Implantable/external loop recorderd (ILR) Recurent syncopies of unknown etiology, susp. VT with negative EP study Diagnosis: syncope + arrhythia, serious arrhythmia Syncope without ECG correlation rules out arrhythmic cause

Further examination Diagnostic methods Electrophysiologic study Restricted indications, suspected arrhythmic cause whithout non-invasice proof Echocardiography Risk stratification, dg. SOS Stress test Psychiatric examination Neurological examination

Take home messages Not every LOC is a syncope. A thorough history is utmost important. Initial workup yields in diagnosis in about 25-40% of cases, in the other cases we stratify risk. There are various diagnotic tests and therapeutic options. The basis is their reasonable and well-targeted use.