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Cardiovascular syncope

Cardiogenic Syncope


Cardiovascular syncope is a brief loss of consciousness (from a few seconds to a few minutes), that is characterized by rapid onset and spontaneous recovery.

Transient loss of consciousness is a dramatic symptom, which has many possible mechanisms and hence different therapeutic, psychosocial, and prognostic implications. It is a common cause both for emergency room visits and for hospitalisation.

Tentative strategy for evaluation of the cardiovascular mechanism of syncope in a patient without palpitations or history of familial (genetic) disease predisposing to loss of consciousness, and episodes less frequent than weekly. A surface ECG is considered a mandatory part of the initial evaluation, as well as hospitalisation and ECG monitoring, if the patient arrives at the emergency department because of a recent episode. Echocardiography for evaluation of cardiac structure and function is a useful early investigation.

Surface ECG abnormal, but not immediately diagnostic
A Cardiovascular disorders:
    Q waves suggesting myocardial infarction, or other signs of ischaemic heart disease
    Negative T waves in V1–3 with/without epsilon waves, suggestive of arrhythmogenic right ventricular dysplasia (cardiomyopathy)
    High amplitudes with/without ST segment depression and negative T waves in left sided precordial leads, suggestive of left ventricular hypertrophy
B Primary electrophysiologic abnormalities:
    Prolonged QT interval
    Right bundle branch block pattern with ST elevation in V1–3, suggestive of the Brugada syndrome
    Bifascicular block* or undetermined intraventricular conduction abnormalities (QRS ≥ 0.12 s)
    Mobitz type I second degree atrioventricular block
    Sinus bradycardia (< 50 beats/min) or sinus pauses
Invasive electrophysiological testing or therapeutic actions without further delay
Surface ECG normal
A In a young person with normal physical examination, first episode:
    Head-up tilt testing
    If there are recurrent episodes, also:
    Evaluation of the presence of SHD with echocardiography and stress testing
    Holter monitoring 48 hours
    Implantable loop recorder
B In a middle aged person:
    Evaluation of the presence of SHD:
    SHD yes: Invasive electrophysiologic study
        Head-up tilt testing
        Implantable loop recorder
    SHD no: Head-up tilt testing
        Implantable loop recorder
        (Invasive electrophysiologic study)
C. In an older person:
    Carotid sinus massage
    Evaluation of the presence of SHD
    Head-up tilt testing
    Invasive electrophysiologic study
    Implantable loop recorder
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