Καρδιακά Αίτια Λιποθυμίας - Συγκοπή Σταύρος Γαβριηλίδης Ομότιμος Καθηγητής ΑΠΘ ΠΡΠ Καρδιολογική Kλινική ΑΠΘ 26/3/2013
Syncope: A Symptom Not a Diagnosis
Significance of Syncope The only difference between syncope and sudden death is that in one you wake up. -- anonomymous --
http://www.escardio.org/guidelines-surveys/esc guidelines/guidelinesdocuments/guidelines-syncope-ft.pdf
Ορισμοί Συγκοπή ορίζεται η πλήρης απώλεια της συνείδησης Οφειλόμενη σε παροδική, σφαιρική εγκεφαλική ισχαιμία χαρακτηριζόμενη από Αιφνίδια έναρξη, Βραχεία διάρκεια, και Αυτόματη πλήρη ανάνηψη Η πλήρης απώλεια της συνείδησης στη νευροααγγειακή συγκοπή (reflex syncope) διαρκεί λιγότερο από 20 s Ο όρος προ-συγκοπή ( pre-syncopal ) χρησημοποιείται για να δηλώσει συμπτώματα και ευρήματα που προηγούνται της απώλειας συνείδησης κατά την συγκοπή
Ταξινόμηση και παθοφυσιολογία 1. Νευροαγγειακή συγκοπή (Reflex syncope - neurally mediated syncope) 2. Ορθοστατική υπόταση και σύνδρομα ορθοστατικής ανεπάρκειας. 3. Καρδιακή συγκοπή (cardiovascular)
Context of transient loss of consciousness (T-LOC).
Καταστάσεις που λανθασμένα διαγιγνώσκονται ως συγκοπή
Αίτια παροδικού χαμηλού ΚΛΟΑ Είναι 3 τύπων 1. Ο πρώτος είναι ο καρδιοανασταλτικός τύπος που προκαλεί βραδυκαρδία (cardioinhibitory type of reflex syncope) 2. Ο δεύτερος είναι καρδιοαγγειακός, απότοκος αρρυθμίας και δομικής καρδιακής νόσου, συμπεριλαμβανομένης της πνευμονικής υπέρτασης / εμβολής 3. Ο τρίτος είναι η ανεπαρκής φλεβική επαναφορά οφειλόμενη σε έλλειμμα υγρών ή φλεβική στάση (orthostatic hypotension (OH),..
Συγκοπή : Αιτιολογία Neurally- Mediated Orthostatic Cardiac Arrhythmia Structural Cardio- Pulmonary Non- Cardiovascular 1 Vasovagal Carotid Sinus Situational Cough Postmicturition 2 Drug Induced ANS Failure Primary Secondary 3 Brady Sick sinus AV block Tachy VT* SVT Long QT Syndrome 4 Aortic Stenosis HOCM Pulmonary Hypertension 5 Psychogenic Metabolic e.g. hyperventilation Neurological 24% 11% 14% 4% 12% DG Benditt, UM Cardiac Arrhythmia Center Unknown Cause = 34%
Συγκοπή: Παθολογοφυσιολογία 1. A sudden cessation of cerebral blood flow for as short as 6 8s has been shown to be sufficient to cause complete LOC. 2. A decrease in systolic BP to 60 mmhg or lower is associated with syncope. 3. Typical syncope is brief. 4. Complete LOC in reflex syncope lasts no longer than 20 s in duration
Forms of reflex syncope in which orthostatic stress is the main trigger 1. Classical OH a decrease in systolic BP >20 mmhg and in diastolic BP >10 mmhg within 3 min of standing 2. Initial OH a BP decrease immediately on standing of > 40 mmhg. BP then spontaneously and rapidly returns to normal, so the period of hypotension and symptoms is short (< 30 s) 3. Delayed (progressive) OH It is attributed to age-related impairment of compensatory reflexes and stiffer hearts in the elderly sensitive to a decrease in preload. Delayed OH is characterized by a slow progressive decrease in systolic BP on assuming erect posture. The absence of a bradycardiac reflex (vagal) differentiates delayed OH from reflex syncope. 4. Postural orthostatic tachycardia syndrome (POTS). Some patients, mostly young women, present with severe complaints of orthostatic intolerance, but not syncope, with very marked heart rate (HR) increases [> 30 b.p.m or to > 120 b.p.m. and instability of BP. ( chronic fatigue syndrome.)
Epidemiology
Rhythms During Recurrent Syncope Bradycardia Normal Sinus Rhythm Normal Sinus Rhythm 58% 58% 36% Tachyarrhythmia 6% Krahn A, et al. Circulation. 1999; 99: 406-410
Η σημασία της συγκοπής infrequent, unexplained: 38% to 47% 1-4 explained: 53% to 62% 500,000 new syncope patients each year 5 170,000 have recurrent syncope 6 70,000 have recurrent, infrequent, unexplained syncope 1-4 1 Kapoor W, Med. 1990;69:160-175. 2 Silverstein M, et al. JAMA. 1982;248:1185-1189. 3 Martin G, et al. Ann Emerg. Med. 1984;12:499-504. 4 Kapoor W, et al. N Eng J Med. 1983;309:197-204. 5 National Disease and Therapeutic Index, IMS America, Syncope and Collapse #780.2; Jan 1997-Dec 1997. 6 Kapoor W, et al. Am J Med. 1987;83:700-708.
Prevalence of the causes of syncope
Prevalence of the causes of syncope 1. Reflex syncope is the most frequent cause of syncope in any setting. 2. Syncope secondary to cardiovascular disease is the second most common cause 3. In patients < 40 years OH is a rare cause of syncope; OH is frequent in very old patients. 4. Non-syncopal conditions, misdiagnosed as syncope at initial evaluation, are more frequent in emergency referrals and reflect the multifactorial complexity of these patients. 5. The high unexplained syncope rate in all settings justifies new strategies for evaluation and diagnosis.
Πρόγνωση 1. Κίνδυνος θανάτου και καταστάσεων απειλητικών της ζωής 2. Κίνδυνος υποτροπής της συγκοπής και τραυματισμού
Θνητότητα και νοσηρότητα
Αρχική αξιολόγηση.. Μάλαξη καρωτιδικού κόλπου σε αρρώστους >40 years. Ηχωκαρδιογράφημα ( σε γνωστή καρδιοπάθεια) Άμεση ΗΚΓκή καταγραφή (arrhythmic syncope). Έλεγχος για ορθοστατική υπόταση (lying-to-standing orthostatic test and/or head-up tilt testing) Λοιπά λιγότερο ειδικά τεστ ( ενδείκνυνται μόνον επί υποψίας μη συγκοπικής ολικής απώλειας συνείδησης)
Αρχική αξιολόγηση.. Είναι ή όχι συγκοπικό το επεισόδιο; Καθορίστηκε αιτιολογικά η διάγνωση; Υπάρχουν δεδομένα για υψηλού κινδύνου επεισόδια ή θάνατο;
Διάγνωση της συγκοπής Οι ακόλουθες ερωτήσεις θα πρέπει να απαντηθούν: 1. Η Απώλεια συνείδησης ήταν πλήρης; 2. Η Απώλεια συνείδησης ήταν ταχείας έναρξης και βραχείας διάρκειας 3. Ο άρρωστος επανήλθε αυτόματα, πλήρως και χωρίς επιπτώσεις; 4. Ο άρρωστος διατηρεί την όρθια θέση; Μ ε την αρχική αξιολόγηση καθορίζεται η αιτία της συγκοπής σε ποσοστό 23 50% των αρρώστων
Εκτίμηση κινδύνου
Διαγνωστικά τεστ 1. Carotid sinus massage 2. Orthostatic challenge - Active standing - Tilt testing
Ηλεκτροκαρδιογραφική παρακολούθηση (αναίμακτη και αιματηρή) 1. In-hospital monitoring (high risk) 2. Holter monitoring (1 2%) 3. Prospective external event recorders (no role) 4. External loop recorders 5. Implantable loop recorders 6. Remote (at home) telemetry (?) 7. Electrocardiographic monitoring in syncope where in the work-up?.....
Ηλεκτροφυσιολογική (EPS) μελέτη Η διαγνωστική της ικανότητα στον καθορισμό της αιτίας της συγκοπής εξαρτάται από Τον βαθμό της υποψίας της ανωμαλίας(pre-test probability), Το πρωτόκολλο της EPS Ευαισθησία και η ειδικότης της EPS γενικώς δεν είναι καλές
Ηλεκτροφυσιολογική (EPS) μελέτη Υποψία διαλείπουσας βραδυκαρδίας Συγκοπή σε αρρώστους με σκελικό αποκλεισμό (υποκρυπτόμενος υψηλού βαθμού κ-κοιλιακός αποκλεισμός) Υποψία για ταχυκαρδία
Adenosine triphosphate test 1. The test requires the rapid (< 2 s) injection of a 20 mg bolus of ATP (or adenosine) during ECG monitoring. 2. The induction of AV block with ventricular asystole lasting > 6 s, or the induction of AV block lasting > 10 s, are considered abnormal. in some patients with syncope of unknown origin 3. the low predictive value of the test does not support its use in selecting patients for cardiac pacing. The role of the so-called adenosine-sensitive syncope remains under investigation.
Ηχωκαρδιογραφία και λοιπές απεικονιστικές τεχνικές
Δοκιμασία κόπωσης
Καρδιακός καθετηριασμός.. Πρέπει να γίνεται 1. σε υποψία ισχαιμίας ή ΕΜ 2. για τον αποκλεισμό αρρυθμιών οφειλόμενων σε ισχαιμία
Ψυχιατρική αξιολόγηση Η συγκοπή και η ψυχιατρική εμπλέκονται με δύο τρόπους 1. Διάφορα ψυχιατρικά φάρμακα δυνατόν να συμμετέχουν στη συγκοπή (OH and prolonged QT intervals.) 2. Αλληλοεπιδράσεις που αφορούν λειτουργικές attacks ψευδοεπιλεψία, ψυχογενής συγκοπή,
Νευρολογική εκτίμηση 1.Ανεπάρκεια του ΑΝΣ 2.Κρανιοαγγειακές διαταραχές 3.Ημικρανία 4.επιληψία Νευρολογικά τεστ Electroencephalography, CT, MRI, Neurovascular studies No studies suggest that carotid Doppler ultrasonography is valuable in patients with typical syncope
Θεραπεία Οι πρωταρχικοί στόχοι της θεραπείας είναι Επιμηκύνουν την επιβίωση, Μειώσουν τους τραυματισμούς, Τις υποτροπές. Η σημασία και η προτεραιότητα των στόχων εξαρτάται από την αιτία της συγκοπής.
The general framework of treatment is based on risk stratification and the identification of specific mechanisms when possible
Treatment of reflex syncope and Reflex syncope Therapeutic options Physical counterpressure manoeuvres Tilt training Pharmacological therapy? Cardiac pacing Individual conditions Vasovagal syncope Situational syncope Carotid sinus syndrome orthostatic intolerance
Orthostatic hypotension and orthostatic intolerance syndromes 1. The principal treatment strategy in drug-induced ANF is elimination of the offending agent. 2. Expansion of extracellular volume is an important goal. sufficient salt and water intake, (2 3 L of fluids per day and 10 g of NaCl). 3. Rapid cool water ingestion is reported to be effective in combating orthostatic intolerance and post-prandial hypotension. 4. Sleeping with the head of the bed elevated prevents nocturnal polyuria, maintains a more favourable distribution of body fluids, and ameliorates nocturnal hypertension.
Cardiac arrhythmias as primary cause. Sinus node dysfunction Atrioventricular conduction system disease Paroxysmal supraventricular and ventricular Tachycardias Implanted device malfunction..
Sinus node dysfunction In general, cardiac pacemaker therapy is indicated and has proved highly effective in patients with sinus node dysfunction Atrioventricular conduction system disease Cardiac pacing is the treatment of syncope associated with symptomatic AV block.
Paroxysmal supraventricular and ventricular Tachycardias catheter ablation is the first-choice treatment Syncope due to torsade de pointes is not uncommon and is, in its acquired form, the result of drugs which prolong the QT interval. Treatment i 1. Immediate discontinuation of the suspected drug. 2. Catheter ablation or drug therapy should be considered in patients with syncope due to VT in the setting of a normal heart or of heart disease with mild cardiac dysfunction.
Implanted device malfunction 1. More often, syncope in such patients may be unrelated to the device 2. Device/lead replacement is indicated and eliminates the problem. pacemaker syndrome, a condition, which incorporates many possible mechanisms of hypotension 1. In pacemaker syndrome with retrograde AV conduction, - - device re-programming - replacement
Syncope secondary to structural cardiac or cardiovascular disease Treatment varies with the diagnosis. 1. severe aortic stenosis or atrial myxoma, surgical treatment 2. pulmonary embolism, myocardial infarction, pericardial tamponade, treatment to the underlying process. 3. In hypertrophic cardiomyopathy (with or without left ventricle outflow tract obstruction), specific treatment of the arrhythmia is usually warranted; in most of these patients, an ICD should be implanted to prevent SCD.
Unexplained syncope in patients with high risk of sudden cardiac death Ischaemic and non-ischaemic cardiomyopathies Hypertrophic cardiomyopathy Arrhythmogenic right ventricular cardiomyopathy dysplasia Patients with primary electrical diseases
Ischaemic and non-ischaemic cardiomyopathies 1. group of syncope patients with preserved LVEF and negative EPS that do not warrant aggressive treatment with an ICD, 2. those with congestive HF and severely depressed LVEF who warrant an ICD despite the fact that it will not provide protection against syncope.
Syncope in the elderly The most common causes of syncope in the elderly are OH, reflex syncope, especially CSS, and cardiac arrhythmias. 1. OH is not always reproducible in older adults (particularly medicationand age-related). 2. CSM is particularly important to use even if non-specific CSH is frequent without history of syncope. 3. In evaluation of reflex syncope in older patients, tilt testing is well tolerated and safe, 4. Twenty-four hour ambulatory BP recordings may be helpful if instability of BP is suspected (e.g. medication or post-prandial). 5. Due to the high frequency of arrhythmias, an ILR may be especially useful in the elderly with unexplained syncope.
Syncope in paediatric patients.. Diagnostic evaluation in paediatric patients is similar to that in adults. Reflex syncope represents the vast majority lifethreatening cardiac arrhythmia or structural abnormalities In rare cases Two specific conditions occur in early childhood: (1) Infantile reflex syncopal attacks (also called pallid breathholding spells or reflex anoxic seizures), elicited by a brief unpleasant stimulus, are caused by vagally mediated cardiac inhibition. (2) Apnoeic hypoxic T-LOC (also called cyanotic breath-holding spells), are characterized by an expiratory cessation of respiration during crying, leading to cyanosis and usually T-LOC.
Driving and syncope the risk of vehicle accident in patients with a history of syncope is not different from that of the general population of drivers without syncope among 104 patients, 1. 3% of patients with syncope reported it to have occurred while they were driving; 2. only 1% crashed their vehicles., 3. only 9% followed this advice not to drive. 4. Among patients with life-threatening ventricular arrhythmias enrolled in the AVID trial, symptoms suggestive of tachyarrhythmia recurred frequently while driving, but they were unlikely to lead to motor vehicle accidents (0.4% per patient-year). The probability of an accident was lower than the annual accident rate in the general population
Management of syncope in general practice 1. Syncope is a common phenomenon in general practice 2. Recurrent typical VasoVagalS is the most common diagnosis Alarming symptoms are: 1. syncope during exertion, 2. syncope in the lying position, 3. absence of external factors, 4. family history of SCD, or 5. slow recovery from syncope
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