Syncope (medicine)

Syncope (medicine)

ICD-10	R55.
ICD-9	780.2
DiseasesDB	27303
eMedicine	med/3385 ped/2188 emerg/876
MeSH	D013575

Syncope (pronounced /ˈsɪŋkəpi/) is the medical term for fainting, a sudden, usually temporary, loss of consciousness generally caused by insufficient oxygen in the brain either through cerebral hypoxia or through hypotension, but possibly for other reasons. Typical symptoms progress through dizziness, clamminess of the skin, a dimming of vision or greyout, possibly tinnitus, complete loss of vision, weakness of limbs to physical collapse. These symptoms falling short of complete collapse, or a fall down, may be referred to as a syncoptic episode.

Syncope due to hypoxia will normally occur if the air breathed contains less than 16% oxygen at atmospheric pressure. Less than 11% oxygen in the air at this pressure can lead to death by suffocation. However, the amount of oxygen in the air is dependent on the partial pressure of oxygen, meaning that, if a person inhales pressurized gas, e.g., while scuba diving, a breathing gas containing less than 16% oxygen can still contain enough to prevent hypoxia. On the other hand, mountaineers, pilots, and astronauts breathe oxygen-enriched gas because the partial pressure of oxygen in normal air mixture is not enough to prevent hypoxia, since the total pressure is reduced at high altitude. Syncope due to hypoxia can also occur because the lungs are not working properly, because a person is not breathing, because the blood is not circulating, or because the blood's ability to transport oxygen is destroyed or blocked, e.g., by carbon monoxide, which, if present, binds itself to the blood's hemoglobin.

Definition

A pre- or near-syncope is diagnosed if the individual can remember events during the loss of consciousness (i.e., reports remembering dizziness, blurred vision, and muscle weakness, and the fall previous to hitting his or her head and losing consciousness). If the individual remembers feeling dizzy and loss of vision, but not the fall, then it is considered a syncoptic episode.

As loss of consciousness is a symptom for a variety of conditions and syncope is difficult to rule out outside of a hospital, a thorough examination is required in order to determine the cause, including interviews with witnesses as well as evaluation with an electrocardiogram.

Differential diagnosis

Central nervous system ischaemia

The central ischaemic response is triggered by an insufficient level of oxygenated blood in the brain. An ischaemic episode increases oxygen supplied to the brain and reduces the delivery to and use of oxygen in other parts of the body.

Blood is diverted to the brain through vasoconstriction, which reduces blood flow in other body parts, and by increasing the pulse rate, tachycardia. The respiratory system may contribute to oxygen levels through hyperventilation, though a sudden ischaemic episode may also proceed faster than the respiratory system can respond. These processes cause the typical symptoms of fainting: pale skin, rapid breathing, nausea and weakness of the limbs, particularly the legs. If the ischaemia is intense or prolonged, limb weakness progresses to collapse. An individual with very little skin pigmentation may appear to have all color drained from his or her face at the onset of an episode. This effect combined with the following collapse can make a strong and dramatic impression on bystanders.

The weakness of the legs causes most sufferers to sit or lie down if there is time to do so. This may avert a complete collapse, but whether the sufferer sits down or falls down the result of an ischaemic episode is a posture in which less blood pressure is required to achieve adequate blood flow. It is unclear whether this is a mechanism evolved in response to the circulatory difficulties of human bipedalism or merely a serendipitous result of a pre-existing circulatory response.

Vertebro-basilar arterial disease

Arterial disease in the upper spinal cord, or lower brain, causes syncope if there is a reduction in blood supply, which may occur with extending the neck or after drugs to lower blood pressure.

Vasovagal

Vasovagal (situational) syncope—one of the most common types—may occur in scary, embarrassing or uneasy situations, or during blood drawing, coughing, urination or defecation. Other types include postural syncope (caused by a changing in body posture), cardiac syncope (due to heart-related conditions), and neurological syncope (due to neurological conditions). There are many other causes of syncope, including low blood-sugar levels and lung disease such as emphysema and a pulmonary embolus. The cause of the fainting can be determined by a doctor using a complete history, physical, and various diagnostic tests.

The vasovagal type can be considered in two forms:

• Isolated episodes of loss of consciousness, unheralded by any warning symptoms for more than a few moments. These tend to occur in the adolescent age group, and may be associated with fasting, exercise, abdominal straining, or circumstances promoting vaso-dilation (e.g., heat, alcohol). The subject is invariably upright. The tilt-table test, if performed, is generally negative.
• Recurrent syncope with complex associated symptoms. This is so-called Neurally Mediated Syncope (NMS). It is associated with any of the following: preceding or succeeding sleepiness, preceding visual disturbance ("spots before the eyes"), sweating, light-headedness. The subject is usually but not always upright. The tilt-table test, if performed, is generally positive.

A pattern of background factors contributes to the attacks. There is typically an unsuspected relatively low blood volume, for instance, from taking a low-salt diet in the absence of any salt-retaining tendency. Heat causes vaso-dilatation and worsens the effect of the relatively insufficient blood volume. That sets the scene, but the next stage is the adrenergic response. If there is underlying fear or anxiety (e.g., social circumstances), or acute fear (e.g., acute threat, needle phobia), the vaso-motor centre demands an increased pumping action by the heart (flight or fight response). This is set in motion via the adrenergic (sympathetic) outflow from the brain, but the heart is unable to meet requirement because of the low blood volume, or decreased return. The high (ineffective) sympathetic activity is always modulated by vagal outflow, in these cases leading to excessive slowing of heart rate. The abnormality lies in this excessive vagal response. The tilt-table test typically evokes the attack. Much of this pathway was discovered in animal experiments by Bezold (Vienna) in the 1860s. In animals, it may represent a defence mechanism when confronted by danger ("playing possum"). This reflex occurs in only some people and may be similar to that described in other animals.

The mechanism described here suggests that a practical way to prevent attacks would be, what might seem to be counterintuitive, to block the adrenergic signal with a beta-blocker. A simpler plan might be to explain the mechanism, discuss causes of fear, and optimise salt as well as water intake.

Deglutition syncope

Syncope may occur during deglutition. Manisty et al note: "Deglutition syncope is characterised by loss of consciousness on swallowing; it has been associated not only with ingestion of solid food, but also with carbonated and ice-cold beverages, and even belching."^[1]

Cardiac

Cardiac causes of syncope can be fatal. Cardiac causes can be divided into two types: cardiac arrhythmias and obstructive cardiac lesions.

Cardiac arrhythmias

Most common cause of cardiac syncope. Two major groups of arrhythmias are bradycardia and tachycardia. Bradycardia can be caused by heart blocks. Tachycardias include SVT (supraventricular tachycardia) and VT (ventricular tachycardia). SVT does not cause syncope except in Wolff-Parkinson-White syndrome. Ventricular tachycardias originate in the ventricles. VT causes syncope and can result in sudden death. Ventricular tachycardia, which describes a heart rate of over 100 beats per minute with at least three irregular heartbeats as a sequence of consecutive premature beats, can degenerate into ventricular fibrillation, which requires DC cardioversion.

Obstructive cardiac lesion

Aortic stenosis and mitral stenosis are the most common examples. Aortic stenosis presents with repeated episodes of syncope. Pulmonary embolism can cause obstructed blood vessels. High blood pressure in the arteries supplying the lungs (pulmonary artery hypertension) can occur during pulmonary embolism. Rarely, cardiac tumors such as atrial myxomas can also lead to syncope.

Other cardiac causes

Sick sinus syndrome, a sinus node dysfunction, causing alternating bradycardia and tachycardia. Often there is a long pause asystole between heartbeat.

Adams-Stokes syndrome is a cardiac syncope which may occur with seizures caused by complete or incomplete heart block. Symptoms include deep and fast respiration, weak and slow pulse and respiratory pauses that may last for 60 seconds.

Aortic dissection (a tear in the aorta) and cardiomyopathy can also result in syncope.

Other causes

Factors that influence fainting are fasting long hours, taking in too little food and fluids, low blood pressure, hypoglycemia, growth spurts, physical exercise in excess of the energy reserve of the body, emotional distress, pregnancy^[2] and lack of sleep. Orthostatic hypotension caused by standing up too quickly or being in a very hot room can also cause fainting.

More serious causes of fainting include cardiac (heart-related) conditions such as an abnormal heart rhythm (an arrhythmia), wherein the heart beats too slowly, too rapidly, or too irregularly to pump enough blood to the brain. Some arrhythmias can be life-threatening. Other important cardio-vascular conditions that can be manifested by syncope include subclavian steal syndrome and aortic stenosis.

Fainting can also occur following hyperventilation prior to a breath-hold dive in shallow water or on ascent from a breath-hold dive in deep water.

Diagnostic approach

Clinical tests

If one is suffering from syncope, there are many underlying causes that may be contributing to the episodes. It is important to understand that there is no master list of tests that are currently being used to diagnose the underlying cause(s). However, there are some common diagnostic tests for fainting.

Blood tests

A hemoglobin count may indicate anemia or blood loss. However, this has been shown to be useful in only about 5% of patients being evaluated for fainting ^[3]

Electrocardiograms

An electrocardiogram (ECG) records the electrical activity of your heart. It is estimated that from 20%-50% of patients will have an abnormal ECG. However, while an ECG may identify conditions such as atrial fibrillation, heart block, or a new or old heart attack, it typically does not provide a definite diagnosis for the underlying cause for fainting.^[4]

Holter monitor testing

Sometimes, one may be asked to wear a Holter monitor. This is a portable ECG device that can record the wearer's heart rhythms during daily activities over an extended period of time. Since fainting usually does not occur upon command, a Holter monitor can provide a better understanding of the heart's activity during fainting episodes.

Tilt table test

Tilt table test is perhaps the most common test performed for syncope. Though it can be helpful, the purpose is to induce a fainting episode, and, thus, is not necessarily conclusive in why this occurs.

Insertable Cardiac Monitor

For patients with more than two episodes of syncope and no diagnosis on “routine testing”, an insertable cardiac monitor is the tool of choice. It is simple to insert, relatively painless for the patient and lasts 14 to 18 months. Smaller than a pack of gum, it is inserted just beneath the skin in the upper chest area. The procedure typically takes 15 to 20 minutes. Once inserted, the device continuously monitors the rate and rhythm of the heart. Upon waking from a “fainting” spell, the patient places a hand held pager size device called an Activator over the implanted device and simply presses a button. This information is stored and retrieved by their physician.

San Francisco syncope rule

Anyone with high risk criteria needs to be further investigated. They are summed up by the CHESS mnemonic: congestive heart failure, hematocrit <30%, electrocardiogram abnormality, shortness of breath, or systolic blood pressure <90 mm Hg.^[5]

Management

Recommended treatment involves returning blood to the brain by positioning the person on the ground, with legs slightly elevated or leaning forward and the head between the knees. As the dizziness and the momentary blindness passes, the person may experience a brief period of visual disturbances in the form of phosphenes, sudden sore throat, nausea, and general shakiness. After the symptoms have passed, sleep is recommended.

Society and culture

Fainting in women was a commonplace trope or stereotype in Victorian England and in contemporary and modern depictions of the period. This may have been partly due to genuine ill-health (the respiratory effects of corsets are frequently cited), but it was fashionable for women to affect an aristocratic frailty and create a scene by fainting at a dramatic moment.

Individuals sometimes will play the 'fainting game', deliberately restricting blood flow to the brain in order to induce syncope, which can result in brain damage and death.^[6]

References

References

• Grubb, Blair P. The Fainting Phenomenon; Understanding Why People Faint and What to Do About It. 2001. 2nd ed. New York: Blackwell Publishing, 2007

External links

• 2004 European Society of Cardiology Guidelines on Management (Diagnosis and Treatment) of Syncope.
• Dysautonomia Information Network
• Tilt table test
• San Francisco syncope rule