内科学教学课件：Syncope

SyncopeDefinition

TransientselflimitedlossofconsciousnessusuallyleadingtofallingDuetosuddentransientglobalcerebralhypoperfusionSyncope:

A

Symptom…NotaDiagnosis

Self-limitedlossofconsciousnessandposturaltoneRelativelyrapidonsetVariablewarningsymptomsSpontaneouscompleterecoveryTheSignificanceofSyncopeTheonlydifferencebetweensyncopeandsuddendeathisthatinoneyouwakeup.11EngelGL.Psychologicstress,vasodepressorsyncope,andsuddendeath.AnnInternMed1978;89:403-412.

PrevalenceandImpactTheSignificanceofSyncope1NationalDiseaseandTherapeuticIndexonSyncopeandCollapse,ICD-9-CM780.2,IMSAmerica,19972BlancJ-J,L’herC,TouizaA,etal.EurHeartJ,2002;23:815-820.3DaySC,etal,AMJofMed19824KapoorW.Evaluationandoutcomeofpatientswithsyncope.Medicine1990;69:160-175TheSignificanceofSyncope500,000newsyncopepatientseachyear5170,000haverecurrentsyncope670,000haverecurrent,infrequent,unexplainedsyncope1-4explained:

53%to62%infrequent,unexplained:

38%to47%1-41KapoorW,Med.1990;69:160-175.2SilversteinM,etal.JAMA.1982;248:1185-1189.3MartinG,etal.AnnEmerg.Med.1984;12:499-504.4KapoorW,etal.NEngJMed.1983;309:197-204.5NationalDiseaseandTherapeuticIndex,IMSAmerica,SyncopeandCollapse#780.2;Jan1997-Dec1997.6KapoorW,etal.AmJMed.1987;83:700-708.1DaySC,etal.AmJofMed1982;73:15-23.2KapoorW.Medicine1990;69:160-175.3SilversteinM,SagerD,MulleyA.JAMA.1982;248:1185-1189.4MartinG,AdamsS,MartinH.AnnEmergMed.1984;13:499-504.SomecausesofsyncopearepotentiallyfatalCardiaccausesofsyncopehavethehighestmortalityratesTheSignificanceofSyncopeImpactofSyncope1Linzer,JClinEpidemiol,1991.2Linzer,JGenIntMed,1994.Anxiety/

DepressionAlterDaily

ActivitiesRestricted

DrivingChange

Employment73%171%260%237%2ProportionofPatients

EtiologySyncope:EtiologyOrthostatic(直立性)CardiacArrhythmiaStructuralCardio-Pulmonary*1VasovagalCarotidSinus• SituationalCoughPost-micturition(排尿)2DrugInduced•ANS FailurePrimarySecondary3BradySicksinusAVblock• TachyVTSVTLongQTSyndrome4AorticStenosisHOCM•PulmonaryHypertension5Psychogenic• Metabolic e.g.hyper- ventilationNeurologicalNon-Cardio-vascularNeurally-MediatedUnknownCause=34%24%11%14%4%12%DGBenditt,UMCardiacArrhythmiaCenter

Diagnosisand

EvaluationOptionsInitialEvaluation

(Clinic/EmergencyDept.)DetailedhistoryPhysicalexamination12-leadECGEchocardiogram(asavailable)Syncope

BasicDiagnosticStepsDetailedHistory&PhysicalDocumentdetailsofeventsAssessfrequency,severityObtaincarefulfamilyhistoryHeartdiseasepresent?

PhysicalexamECG:longQT,WPW,conductionsystemdiseaseEcho:LVfunction,valvestatus,HOCMFollowadiagnosticplan...Syncope

EvaluationandDifferentialDiagnosisCompleteDescriptionFrompatientandobserversTypeofOnsetDurationofAttacksPostureAssociatedSymptomsSequelae(后遗症)History–WhattoLookfor12-LeadECGNormalorAbnormal?AcuteMISevereSinusBradycardia/pauseAVBlockTachyarrhythmia(SVT,VT)Preexcitation(WPW),LongQT,BrugadaMethodCommentsHolter(24-48hours)UsefulforinfrequenteventsEventRecorderUsefulforinfrequenteventsLimitedvalueinsuddenLOCLoopRecorderUsefulforinfrequenteventsImplantabletypemoreconvenient(ILR)Wireless(internet)EventMonitoringIndevelopmentAmbulatoryECGValueofEventRecorderinSyncopeLinzerM.AmJCardiol.1990;66:214-219.*AsteriskdenoteseventmarkerPatientActivatorReveal®PlusILR9790ProgrammerReveal®Plus

InsertableLoopRecorderILRRecordings*56yowomanwithsyncopeaccompaniedwithseizures.Infra-HisianAVBlock:Dualchamberpacemaker65yomanwithsyncopeaccompaniedwithbriefretrogradeamnesia(逆行性遗忘).VTandVF:ICDandmeds*MedtronicdataonfileConventionalEPTestinginSyncope

LimitedutilityinsyncopeevaluationMostusefulinpatientswithstructuralheartdiseaseHeartdisease……..50-80%NoHeartdisease…18-50%RelativelyineffectiveforassessingbradyarrhythmiasBrignoleM,AlboniP,BendittDG,etal.EurHeartJournal2001;22:1256-1306.EPTestinginSyncope:

UsefulDiagnosticObservationsInduciblemonomorphicVTSNRT>3000msorCSRT>600msInducibleSVTwithhypotensionHVinterval≥100ms(especiallyinabsenceofinducibleVT)Pacinginducedinfra-nodalblockHead-upTiltTest(HUT)UnmasksVVSsusceptibilityReproducessymptomsPatientlearnsVVSwarningsymptomsPhysicianisbetterabletogiveprognostic/treatmentadvice

Whatisatilt?Quiet60-70degrees30-40minuteswithorwithoutGTNContinuousnoninvasiveHRandBPmonitoringLookingforBPandHRchangesandsymptomreproductionCanmodifyforsituationaleventsDiagnosingVVSPatienthistoryandphysicalexamPositivetilttabletest

(ACCConsensusProtocol)OvernightfastECGBloodpressureSupineanduprightTiltto60-80degreesIsoproterenol(异丙肾上腺素)Re-tiltDGBenditt,TiltTableTesting,1996.60°-80°CarotidSinusMassageSite:Carotidarterialpulsejustbelowthyroidcartilage(甲状软骨Method:Rightfollowedbyleft,pausebetweenMassage,NOTocclusionDuration:5-10secPosture–supine&erectCarotidSinusMassageOutcome:

3secasystoleand/or50mmHgfallinsystolicbloodpressurewithreproduction

ofsymptoms=CarotidSinusSyndrome(CSS)ContraindicationsCarotidbruit,knownsignificantcarotidarterialdisease,previousCVA,MIlast3monthsRisks1in5000massagescomplicatedbyTIAElectroencephalogram(脑电图)NotafirstlineoftestingSyncopefromSeizures(发作)Abnormalintheintervalbetweentwoattacks–Epilepsy(癫痫)Normal–SyncopeTypicalCardiovascularDiagnosticPathwayHistoryandPhysical,ECGSyncopeKnown

SHD(StructuralHeartDisease)

No

SHD

EchoEPS电生理检查

+Treat>30days;>2EventsTiltILRTiltHolter/ELRILRTilt/ILR<30days-Adaptedfrom:LinzerM,etal.AnnalsofIntMed,1997.127:76-86.Syncope:MechanismsandManagement.GrubbB,OlshanskyB(eds)FuturaPublishing1999ZimetbaumP,JosephsonM.AnnalsofIntMed,1999.130:848-856.KrahnAetal.ACCCurrentJournalReview,1999.Jan/Feb:80-84.DiagnosticLimitationsDifficulttocorrelatespontaneouseventsandlaboratoryfindingsOftenmustsettleforanattributablecauseUnknownsremain20-30%11KapoorW.InGrubbB,OlshanskyB(eds)Syncope:MechanismsandManagement.ArmonkNY;FuturaPublishingCo,Inc:1998;1-13.

InsightsintoMoreEfficientandEffectiveDiagnosisandTreatmentPrincipalCausesof

OrthostaticSyncopeDrug-induced(verycommon)diureticsvasodilators

PrimaryautonomicfailuremultiplesystematrophyParkinsonismSecondaryautonomicfailurediabetesalcoholamyloidAlcohol

orthostaticintoleranceapartfromneuropathy

SyncopeDuetoArrhythmiaorStructuralCVDisease:

GeneralRules

Oftenlife-threateningand/orexposespatienttohighriskofinjuryMaybewarningofcriticalCVdiseaseAorticstenosis,Myocardialischemia,PulmonaryhypertensionAssessculpritarrhythmia/structuralabnormalityaggressivelyInitiatetreatmentpromptlyPrincipalCausesofSyncopeduetoStructuralCardiovascularDiseaseAcuteMI/IschemiaAcquiredcoronaryarterydiseaseCongenitalcoronaryarteryanomaliesHOCMAcuteaorticdissectionPericardialdisease/tamponade(压塞)Pulmonaryembolus/pulmonaryhypertensionValvularabnormalitiesAorticstenosis,Atrialmyxoma(黏液瘤)SyncopeDuetoCardiacArrhythmiasBradyarrhythmiasSinusarrest,exitblockHighgradeoracutecompleteAVblockTachyarrhythmiasAtrialfibrillation/flutterwithrapidventricularrate(e.g.WPWsyndrome)ParoxysmalSVTorVTTorsadesdepointesAECG:74yrMale,SyncopeFromthefilesofDGBenditt,UMCardiacArrhythmiaCenter83yowomanBradycardia:Pacemakerimplanted28yomanintheERmultipletimesafterfallsresultingintraumaVT:ablatedandmedicatedReveal®ILRrecordings;Medtronicdataonfile.TreatmentofSyncopeDuetoBradyarrhythmiaClassIindicationforpacingusingdual-chambersystemwhereveradequateatrialrhythmisavailableVentricularpacinginatrialfibrillationwithslowventricularre