1. SWOONING AND VAPORS Syncope and near syncope

3. Syncope accounts for 3% ER visits Syncope/pre-syncope symptoms are due to a reduction in cerebral perfusion, most often as result of decreased blood pressure.

4. Blood pressure is dependent on Cardiac output Vascular tone Vascular volume

5. Cardiac output HEART RATE: too slow/fast, arrhythmias MECHANICAL: aortic/mitral stenosis; pulmonary emboli; HOCUM; Cardiomyopathy

6. VASCULAR VOLUME Blood loss dehydration

7. VASCULAR TONE Drugs Neuromediated Autonomic insuffiency Orthostasis Vascular disease-carotid, vertebralbasilar

8. CAUSES OF SYNCOPE Cardiac:14% arrhythmia/ 4% mechanical Neurologic: 10% Neurally mediated: Vasovagal 18-25% Orthostatic: 8-10% Psychiatric: 2% No clear etiology 33-45%

9. PROGNOSIS VARIES WITH ETIOLOGY Cardiac syncopeNon-cardiac syncope – 25% 1 year mortality-7% 1 year mortality – 14% 1 year CSD-3% 1 year CSD

10. HISTORY AND PHYSICAL More than 50% of diagnosis should come from History and Physical

11. Prior incidence? Behavior at time of event Symptoms prodrome? Duration of LOC? Mental status afterwards Witness information?

12. BEHAVIOR/CONDITIONS Postural change Cough Swallowing Head turning/neck pressure Defecation Pain Strong emotion Prolonged standing At rest or with activity Tremor seizure activity

13. Symptoms Nausea Pallor Warmth/flushed Diaphoresis Palpitations Visual/hearing changes Confusion headache

14. Duration of LOC/event seconds-hours Mental status after postictal/washed out Witness information

15. Past medical History Structural heart disease Previous heart rhythm problems Seizure history Vascular disease Drugs and recent changes

16. PHYSICAL EXAM Vital signs, including orthostatic blood pressures->20 mmHg drop in BP with standing Carotid hypersensitivity>3 sec pause, 50 mmHg asymptomatic or 30 mmHg symptomatic BP drop (up to 5 sec massage) Bruits Murmur Neurological findings

17. diagnostics ECG 5% unselected diagnostic yield – Long QT; afib/flutter; MAT; paced; VPB; V tach; bundle branch block; LVH; Old MI;WPW; Mobitiz type II – ECHO: 5-10 %unselected diagnostic yield – EST: activity associated symptoms – Monitor holter/event monitor – Tilt table test

18. NEUROCARDIOGENIC SYNCOPE Very common 20-25% in most series Usually manifests by second decade of life Abnormal reflex-mediated – Usually upright position – Trigger/prodrome – Decreased venous return; increased LV contractility; mechanical receptor activation— leads to—vasodilatation/bradycardia—manifests as hypotension-syncope

19. SYCOPE DIAGNOSIS SCORING SYSTEM PATIENT FEATUREPOINTS Female, <42 yrs7 Syncope/presyncope – Headache/flushing/pain3 for each – Nausea2 – Diaphoresis2 – Male <43 yrs2 – Prolonged orthostasis1 – Cyanosis-4 – Diabetes-4 – Bifasicular block-3 – Chest pain with fainting-2 – Postictal confusion-1 – Memory of fainting-1 – Score 3 or > vasovagal syncope; score 2 or less another source

20. NEUROCARDIOGENIC SYNCOPE Triggers: pain; strong emotion/stress; prolonged standing Situational: micturation; defication; cough; deglutation

21. PREDICTORS OF POOR OUTCOME IN SYNCOPE PATIENTS Abnormal ECG-non-specific ST or sinus tachycardia Prior ventricular arrhythmia >10VPB/hr; VPB pairs; multifocal VPB CHF history Age >45 years (without prior history of syncope) If 05% 1year arrhythmia/death If 110% If 3-460%

22. WHEN TO HOSPITALIZE History of chest pain Hx of CAD, CHF, Ventricular ectopy Evidence of CHF,AS, focal neuro defect ECG abnl.-BBB; ischemia; MI;arrhythmia Consider-for exertional syncope; frequent spells; age >70 yr; orthostasis; sustained physical injury; suspected ACS