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Syncope

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Version Jan 2023

The immediate management of syncope or impending syncope is to lie the patient down and raise their legs increasing cerebral blood flow.

About

Defined as a transient loss of consciousness (TLOC) due to inadequate cerebral blood flow.

Pathophysiology

Mainly a function of blood pressure control and as we know BP = CO x PR
A fall in PR due to vasodilation, anaphylaxis, vascular relaxing meds e.g. GTN
A fall in CO (CO = HR x SV) due to aortic stenosis, arrhythmia, volume loss

Clinical features

Was there a warning - did the patient anticipate the episode. Remembers hitting the ground.
Was there pain, breathless beforehand.

Causes

Type	Details
Vasovagal syncope	Clinical context - vasovagal often situational - church, standing in line, hot bath, on toilet having severe gastroenteritis and usually sitting up or standing. Vasovagal usually hearing goes distant with tinnitus as does vision and sense of impending syncope. The patient goes pale. Then rapidly spontaneously recover once they go to the ground. Flushed and sweaty but not confused. May have urinary incontinence. May jerk. Ask about precipitants, standing, fear, venesection, micturition or pain.
Postural syncope (fainting on standing)	Seen in patients with autonomic disorders, salt and water depletion, hypovolaemia or due to certain drugs especially antianginal and antihypertensive medication.
Cardiac arrhythmias may reduce CO and result in syncope.	This may occur in bradycardias or tachycardias (inadequate ventricular filling time). The loss of consciousness occurs irrespective of the patient posture. A Stokes-Adams the attack is a loss of consciousness related to a sudden loss of ventricular contraction particularly seen during the progression from second to third-degree heart block.
Carotid sinus syncope	A rare condition mainly seen in the elderly. As a result of hypersensitivity of the carotid sinus, light pressure, such as that exerted by a tight collar, causes severe reflex bradycardia and hence syncope.
Exertional syncope	occurs in aortic valve or subvalve stenosis. The syncope results from an inability of the heart to increase cardiac output in response to increased demand.

Cardiac Causes of syncope

Severe aortic stenosis
Severe bradycardia e.g. complete heart block or sinus pauses
Vasovagal syncope exacerbated by medications
Ventricular tachycardia (see causes)
Stokes-Adams attack

Clinical

Get a detailed history of every second to the event. Was it truly syncope - did they appear Dead.
How quickly was recovery. Any injury. any incontinence. Any protective injuries e.g. fall on outstretched hand.
Getting a witness history is key even if you need to call them in the clinic with pt permission.
Assess Lying standing BP
Look for rare Addison's disease - usually low BP, pigmented
Look for murmurs - Aortic stenosis and HCM

Investigations

FBC, U&E, CRP, LFT, Ca ALP
ECG: bradycardia, pauses, tachycardia, heart block
CXR: cardiomegaly
Echocardiogram: exclude valve stenosis and exclude cardiomyopathy and poor LV
Carotid dopplers : I would not do without focal neurology
24 to 7 day tape.
Implantable loop recorder
Tilt table testing: This is usually carried out with a mechanised tilt table giving a head-up tilt of 60 degrees for 45 min, with continuous ECG and BP monitoring
Exercise stress test
Coronary angiogram: concerns of IHD

Management

Focus on individual causes: Severe Bradycardia - stop causative drugs. Consider pacemaker

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