The role of clinical assessment and electrophysiology study in Brugada syndrome patients with syncope.

BACKGROUND: Cardiogenic syncope in Brugada syndrome (BrS) increases the risk of major events. Nevertheless, clinical differentiation between cardiogenic and vasovagal syncope can be challenging. We characterized the long-term incidence of major events in a large cohort of BrS patients who presented with syncope. METHODS: From a total of 474 patients, syncope was the initial manifestation in 135 (28.5%) individuals (43.9 ±â€¯13.9 years, 71.1% male). The syncope was classified prospectively as cardiogenic, vasovagal, or undefined if unclear characteristics were present. Clinical, electrocardiographic, genetic, and electrophysiologic features were analyzed. Cardiogenic syncope, sustained ventricular arrhythmias, and sudden death were considered major events in follow-up. RESULTS: In 66 patients (48.9%), the syncope was cardiogenic; in 51 (37.8%), vasovagal and in 18 (13.3%); undefined. The electrophysiology study (EPS) inducibility was more frequent in patients with cardiogenic syncope and absent in all patients with undefined syncope (28 [53.8%] vs 5 [12.2%] vs 0 [0%]; P < .01). During follow-up (7.7 ±â€¯5.6 years), only patients with cardiogenic syncope presented major events (16 [11.9%]). Among patients with inducible EPS, 7 (21.2%) presented major events (P = .04). The negative predictive value of the EPS for major events was 92.4%. The incidence rate of major events was 2.6% person-year. Parameters associated with major events included cardiogenic syncope (hazard ratio [HR] 6.3; 95% CI 1.1-10.4; P = .05), spontaneous type 1 electrocardiogram (HR 3.7; 95% CI 1.3-10.5; P = .01), and inducible EPS (HR 2.8; 95% CI 1.1-8.8; P = .05). CONCLUSIONS: An accurate syncope classification is crucial in BrS patients for risk stratification. In patients with syncope of unclear characteristics, the EPS may be helpful to prevent unnecessary implantable cardioverter defibrillators.

The Cost-Effective Evaluation of Syncope.

Syncope is a common clinical problem that carries a high socioeconomic burden. A structured approach in the evaluation of syncope with special emphasis on a detailed history, comprehensive physical examination that includes orthostatic vital signs, and an electrocardiogram, proves to be the most cost-effective approach. The need for additional testing and hospital admission should be based on the results of the initial evaluation and use of risk-stratification tools that help identify those syncope patients at highest risk for poor outcomes.

Current approaches to the clinical assessment of syncope in pediatric population.

INTRODUCTION: Syncope is one of the most common clinical problem in children. This disorder is characterized by transient, spontaneously self-terminating loss of consciousness with brief duration and complete recovery. This situation is usually alarming for the families of patients. The mechanism of syncope is transient global brain hypoperfusion to levels below those tolerated by cerebrovascular autoregulation. Syncope can occur with many different etiologies in the pediatric population. CLASSIFICATION: Syncopes are divided into three major categories as neurally mediated syncope, cardiovascular-mediated syncope, and non-cardiovascular syncope. CLINICAL FEATURES: The major challenge in the assessment of children with syncope is that most children are asymptomatic at the time of their presentation, therefore making a careful and detailed history and a comprehensive physical examination essential in all patients. A trigger stimulus is detected in some cases, and this is an important clinical clue for the diagnosis. Cardiac causes of syncope in children are rare but can be life threatening and have the highest risk of morbidity and mortality. Misdiagnosis of epilepsy is common in patients presenting with syncope; therefore, the differential diagnosis between epileptic seizures and syncope is very important. It should be remembered that the evaluation of syncope in children is costly and diagnostic workup has a limited diagnostic yield. CONCLUSION: The aim of this article is to present different types of syncope and to provide new practical clinical approaches to the diagnosis, investigation, and management in the pediatric population.

An approach to the clinical assessment and management of syncope in adults.

Syncope, defined as a brief loss of consciousness due to an abrupt fall in cerebral perfusion, remains a frequent reason for medical presentation. The goals of the clinical assessment of a patient with syncope are twofold: (i) to identify the precise cause in order to implement a mechanism-specific and effective therapeutic strategy; and (ii) to quantify the risk to the patient, which depends on the underlying disease,rather than the mechanism of the syncope. Hence, a structured approach to the patient with syncope is required. History-taking remains the most important aspect of the clinical assessment. The classification of syncope is based on the underlying pathophysiological mechanism causing the event, and includes cardiac, orthostatic and reflex (neurally mediated) mechanisms. Reflex syncope can be categorised into vasovagal syncope (from emotional or orthostatic stress), situational syncope (due to specific situational stressors), carotid sinus syncope(from pressure on the carotid sinus, e.g. shaving or a tight collar), and atypical reflex syncope (episodes of syncope or reflex syncope that cannot be attributed to a specific trigger or syncope with an atypical presentation). Cardiovascular causes of syncope may be structural(mechanical) or electrical. Orthostatic hypotension is caused by an abnormal drop in systolic blood pressure upon standing, and is defined asa decrease of >20 mmHg in systolic blood pressure or a reflex tachycardia of >20 beats/minute within 3 minutes of standing. The main causes of orthostatic hypotension are autonomic nervous system failure and hypovolaemia. Patients with life-threatening causes of syncope should be managed urgently and appropriately. In patients with reflex or orthostatic syncope it is important to address any exacerbating medication and provide general measures to increase blood pressure, such as physical counter-pressure manoeuvres. Where heart disease is found to bet he cause of the syncope, a specialist opinion is warranted and where possible the problem should be corrected. It is important to remember that in any patient presenting with syncope the main objectives of management are to prolong survival, limit physical injuries and prevent recurrences. This can only be done if a patient is appropriately assessed at presentation, investigated as clinically indicated, and subsequently referred to a cardiologist for appropriate management.

The development and preliminary validation of a scale measuring the impact of syncope on quality of life.

AIMS: To develop a brief syncope-specific measure of health-related quality of life. METHODS AND RESULTS: One hundred and fourteen patients with syncope completed a 48-item questionnaire derived from a generic measure of quality of life (the EQ-5D), the Syncope Functional Status Questionnaire, a depression scale (the CES-D) and historical symptoms. From these, clinical impact methodology was used to derive 12-item Impact of Syncope on Quality of Life (ISQL). The ISQL correlated with the number of syncopal spells in the previous year (r = 0.35), self-perceived health status (r = -0.55), the three scores from the SFSQ: [impairment (r = 0.77), fear and worry (r = 0.72), syncope dysfunction (r = 0.82), and depression (r = 0.62)], illustrating its convergent validity with these concepts. Known group differences were evident between patients who exhibited reduced quality of life on the EQ-5D and those who did not. There was no significant correlation between ISQL score and age or gender. ISQL score correlated better with the frequency of spells in the previous year than years prior to the previous year. CONCLUSION: The ISQL is a brief valid measure of the impact of syncope on quality of life. It measures impairment, fear, depression, and physical limitations, and correlates with recent syncope frequency.

Síncope: Avaliação diagnóstica e conduta / Syncope: Diagnostic assessment and procedure

Este artigo tem como finalidade oferecer aos clínicos uma atualização sobre síncope, suas causas, mecanismos fisiopatológicos envolvidos bem como as condutas terapêuticas atuais. Consideraçöes especiais serão dirigidas à síncope cardio-neurogênica, sua importância clínica e as diversas opçöes atuais de tratamento. Discutiremos as indicaçöes e metodologias utilizadas no teste de inclinação, bem como a sua utilidade para a definição das diversas formas de apresentação da síncope cardio-neurogênica.

[Clinical assessment of syncopes]. / Inquadramento clinico delle sincopi.

Syncope is a relatively common clinical problem and causes 1% of hospitalizations. The clinical syndrome is characterized by a sudden reduction of the cerebral flow secondary to a number of conditions that includes benign, self-limited causes and life-threatening arrhythmias. A high percentage of these patients is discharged from hospital without an etiological diagnosis. The purpose of this short review is to present the classification of syncope and suggest the methodological approach to detect the underlying cause. The importance of patient's age and of a cardiovascular etiology as a negative prognostic index is stressed. The most valuable diagnostic tool remains a thoroughly taken clinical history.