Syncope

Question 1

Syncope Definition

Answer 1

Transient loss of consciousness caused by transient global cerebral hypoperfusion characterised by rapid onset, short duration, spontaneous complete recovery
-Excludes coma, seizure, shock or other states of altered consciousness

Question 2

Causes of Collapse

Answer 2

-Head (hypoxia, hypoglycaemia, epilepsy, affective, dysfunction of brainstem (TIA, migraine, vertebrobasilar stroke)
Heart (IHD, emboli, aortic obstruction (stenosis, HOCM), rhythm disorders (CHB), tachyarrhythmias
-Vessels (ENT (labyrinthitis, meniere’s), situational (micturition syncope, cough syncope), sensitive carotid sinus, ectopic, low vascular tone, subclavian steal
-Drugs

Question 3

Syncope Causes

Answer 3

Reflex Syncope (neurally mediated)
-Vasovagal (orthostatic/emotional stress)
-Situational (cough, sneeze, micturition..)
-Carotid sinus
-Atypical
Syncope due to Orthostatic Hypertension
-Primary autonomic failure
-Secondary autonomic failure
-Drug induced
-Volume depletion
Cardiac Syncope
-Bradycardia
-Tachycardia
-Drug-induced
-Structural (cardiac+other (PE, dissection))

Question 4

Syncope Epidemiology

Answer 4

-Peak prevalence between 10-30

Question 5

Syncope History

Answer 5

-General
-Did they lose awareness? Did they injure themselves? Did they move? Stiff/floppy? Incontinence? Complexion changes? (pale/cyanosis in epilepsy, very pale/white in arrhythmias and syncope). Tounge biting? Associated symptoms (palipitations, sweats pallor, CP, dyspnoea, how long did the attack last?
-Before
-Any warning.e. aura? What circumstances? Can they prevent attacks?
After
-How much do they remember? Muscle ache (tonic clonic)? Confusion (epilepsy)?
Background
-When did they start? Are they getting more frequent? FHx?

Question 6

Syncope Differentials

Answer 6

Falls, epilepsy, narcolepsy, cataplexy, dizziness, vertigo, TIA, psychogenic pseudo syncope

Question 7

Syncope Ix

Answer 7

Primary Care
-Orthostatic BP measurement
-ECG
-FBC (anaemia/bleeding)
-Fasting blood glucose
Secondary Care
-NMS (carotid sinus massage, tilt testing, implantable loop recorder)
-Cardiac (ECG ambulatory monitoring, ATP test, echo, CT, MRI
-Exercise testing (for those who experience during exertion)
-Tilt testing

Question 8

Syncope Symptoms Suggesting Arrhythmic Cause

Answer 8

• Syncope during exercise
• Palpitations during syncope
• FHx of sudden cardiac death
• Non sustained VT
• Bifascicular block
• Bradycardia, broad QRS, Brugada pattern

Question 9

Syncope Scores

Answer 9

-OESIL, SFSR, EGSYS

Question 10

Syncope Management

Answer 10

NMS
-Explanation, reassurance, education
-Take action on first signs (crouch on heels, wait, get up carefully)
-If persistent can treat with tilt training, counter pressure manoeuvres, medication unhelpful
Orthostatic
-Stop offending drugs, avoid alcohol, raise head of bed, leg crossing, arm tensing

Question 11

Syncope DVLA 3 Ps?

Answer 11

Strong provocation associated with prodromal symptoms and posture (unlikely to occur while sitting or lying)

Question 12

Syncope Prognosis

Answer 12

-Varies according to underlying cause, reflex syncope is fine
-25% have recurrences
If young, syncope is benign
-Outcome depends on cause