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.

[How to Distinguish Syncope from Epileptic and Psychogenic Non-Epileptic Seizures]. / Synkope, epileptischer oder psychogener Anfall? Der Weg zur richtigen Diagnose.

Transient loss of consciousness (TLOC) is a frequent cause of referral to an emergency room. In view of the impact on treatment and the patients' daily life activities (e. g. profession, driving license), an accurate and timely diagnosis is of uttermost importance. This article provides key features and suggests a practical step-by-step approach of how to differentiate syncope, epileptic and psychogenic non-epileptic seizures as the commonest causes of nontraumatic TLOC.

Síncope en una deportista escolar / Syncope in a school athlete

Se presenta el caso de una niña de diez años que sufrió un síncope durante el esfuerzo y que fue diagnosticada de taquicardia ventricular polimórfica catecolaminérgica. Es una canalopatía arritmógena que puede desencadenar arritmias ventriculares graves y alto riesgo de muerte súbita en pacientes jóvenes con un corazón de estructura normal. El síncope es un problema médico común, con una prevalencia estimada del 40% en la población general. Suele tener una evolución benigna, aunque en un 2-3% también puede relacionarse con eventos cardiacos y ser un síntoma de posibilidad de muerte súbita. La anamnesis es esencial para identificar las causas y mecanismos desencadenantes y orientar las pruebas diagnósticas a realizar. En este caso la ergometría fue la prueba diagnóstica, ya que puso en evidencia la arritmia. La decisión sobre la aptitud deportiva será individualizada y dependerá de la etiología del síncope. Se debe establecer el pronóstico y valorar la posibilidad de recurrencias y de muerte súbita y evitar los diagnósticos erróneos tanto de contraindicación como de aptitud deportiva (AU)

We present the case of a 10-year-old girl who suffered syncope during the effort, who was diagnosed with catecholaminergic polymorphic ventricular tachycardia. It is an arrhythmogenic channelopathy that can trigger severe ventricular arrhythmias and has a high risk of sudden death in young patients witch normal heart structure. Syncope is a common medical problem, with an estimated prevalence of 40% in the general population. It usually has a benign course, although 2-3% can also be related to cardiac events and be a symptom of possibility of sudden death. The anamnesis is essential to identify the causes and trigger mechanisms and guide the diagnostic tests to be performed. In this case, the ergometry was the diagnostic test, since it showed the arrhythmia. The decision about the sport aptitude will be individualized and will depend on the aetiology of the syncope. The prognosis should be established and the possibility of recurrences and sudden death should be assessed and the misdiagnosis of both contraindication and sports aptitude should be avoided (AU)

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.

Current Guidelines on Syncope.

Syncope is a very commonly encountered clinical problem in general practice and in the emergency department. In the evaluation of syncope, it is important to identify the specific cause to determine the treatment, to estimate the precise risk to a patient, and to reduce recurrence. Sometimes, making a diagnosis of syncope is difficult, as different mechanisms may often coexist. Syncope causes a significant impact on quality of life due to associated risk of physical injury. In particular, syncope can be a precursor to sudden cardiac death in patients with underlying cardiac disease. It is crucial to identify patients at increased risk of death, such as those with myocardial ischemia and/or potentially life-threatening genetic diseases (e.g., Long-QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, and arrhythmogenic right ventricular dysplasia). After these conditions have been excluded, other benign conditions that cause syncope must be identified, and efforts should be made to improve quality of life. The lack of a gold-standard clinical tool to aid in diagnosing syncope as well as improper use of various diagnostic tests, are leading to high economic burdens in this area.

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.

Managing the military patient with syncope.

Syncope is a relatively common occurrence in military populations. It is defined as a transient loss of consciousness due to global cerebral hypoperfusion, characterised by a rapid onset, short duration and a spontaneous and complete recovery. While the symptom of syncope is easily elicited, discovering the mechanism can be more problematic and may require a plethora of diagnostic tests. The aim of this paper is to review current evidence pertaining to the classification, investigation and management of syncope, from a military perspective. Emphasis is placed on assisting primary healthcare professionals in the assessment and management of syncope, in the UK and on operations, while providing explicit guidance on risk. The occupational limitations required in safely managing patients with syncope are stressed along with the potential long-term limitations.

Syncope: Definition, Epidemiology, and Classification.

Major progress has been made during the last 2 decades on the different aspects of syncope. Most of the progress is the consequence of the acceptance of a clear definition of what is and what is not syncope. However, although this definition is widely accepted by physicians who are "specialists" in syncope, it still remains unknown or challenged by many other physicians. This lack of awareness leads to multiple useless, costly, and painful examinations. The next step is therefore to disseminate the knowledge of this definition and the strategy for diagnosis of syncope.

[Vertigo and syncope: a clinically oriented introduction to the problem]. / Schwindel und Synkope: Eine klinisch orientierte Hinführung zum Problem.

Vertigo and syncope are frequently occurring clinical presentations in the physician's practice as well as in the emergency room. Therefore, many physicians and institutions have formulated diagnostic protocols that they follow when a patient with vertigo or syncope presents. This kind of blanket routine may lead to over-diagnosis in many cases, as well as to under-diagnosis in some. The purpose of the following article is to show that a well-focused history based on clear cut concepts of disease and a sound pathophysiological understanding will guide the physician precisely through the diagnostic process in both clinical presentations and will help to avoid manifold diagnostic procedures. Finally, a description of the most frequent pitfalls of the diagnostic work-up is given, along with measures to avoid these.

[Vertigo/dizziness and syncope from a neurological perspective]. / Schwindel und Synkope aus Sicht des Neurologen.

Vertigo/dizziness and syncope are among the most frequent clinical entities encountered in neurology. In patients with presumed syncope, it is important to distinguish it from neurological and psychiatric diseases causing a transient loss of consciousness due to another etiology. Moreover, central nervous disorders of autonomic blood pressure regulation as well as affections of the peripheral autonomic nerves can be responsible for the onset of real syncope. This is particularly relevant in recurrent syncope. Vertigo occurs in the context of temporary disorders, relatively harmless diseases associated with chronic impairment, as well as in acute life-threatening states. Patient history and clinical examination play an important role in classifying these symptoms. It is of crucial importance in this context, e.g., to establish whether the patient is experiencing an initial manifestation or whether such episodes have been known to occur recurrently over a longer period of time, as well as how long the episodes last. Clinical investigations include a differential examination of the oculomotor system with particular regard to nystagmus. The present article outlines the main underlying neurological diseases associated with syncope and vertigo, their relevant differential diagnoses as well as practical approaches to their treatment.

Clinical significance of second degree Wenckebach type sinoatrial block identified during Holter monitoring in patients with symptoms suggestive of arrhythmia.

AIMS: To determine the clinical significance of the sinoatrial block II° of the Wenckebach type (block W) identified during Holter monitoring. METHODS AND RESULTS: The study included 300 patients (mean age 54 ± 17 years; 130 women) with symptoms suggestive of arrhythmia who underwent Holter monitoring. Block W was identified by a dedicated computer program and subsequently confirmed by a cardiologist. Block W was diagnosed in 88 patients (29%). It occurred only during sleep in 37 (12%) patients and during both daytime activity and sleep in 51 (17%) patients. Block W only during sleep happened predominately in young patients aged between 20 and 30 years, whereas episodes that occurred during both daytime and sleep were found mainly in patients between 60 and 70 years of age. Prospective observation time averaged 41 ± 11 months, and the time to the diagnosis of sinus node disease was 26 ± 10 months. Cox multivariate analyses showed that block W during both daytime and sleep is an independent predictor for the future diagnosis of sinus node disease [hazard ratio-13.6 (5.2-35.5); P < 0.0001]. Age-specific analyses confined this effect to the patients ≥50 years of age. The results also suggest that in patients ≥50 years of age block W during both daytime and sleep may be related to a significant improvement in survival [hazard ratio-0.03 (0.007-0.16); P < 0.0001]. CONCLUSION: Block W during daytime activity in patients with symptoms suggestive of arrhythmia indicates an increased likelihood of the future diagnosis of sinus node disease.

Onset of sweating depends on the type of reflex syncope.

Reflex syncope is classified based on the efferent autonomic system as vasodepressant type, cardioinhibitory type and mixed type. We employed quantitative sweat testing to assess differences in sudomotor sympathetic activity in relation to the type of reflex syncope. In cardioinhibitory type sweating started in 7/9 patients after and in vasodepressor type in 11/12 patients before syncope. In mixed type sweating in 20 patients started before and in 10 after syncope. The onset of sweating correlated significantly with the onset of syncope symptoms. These results possibly reflect different onsets of emotional sweating.

Classifying syncope.

An unambiguous definition of syncope is important for care, research and teaching purposes. Unfortunately, many published definitions described 'syncope' as a broad category of transient loss of consciousness (TLOC) but still appeared to use a much narrower concept, creating confusion. The ESC-classification from 2001 and subsequently distinguished between 'transient loss of consciousness', i.e. disorders sharing unconsciousness of short duration with a rapid and spontaneous recovery and syncope, the form of TLOC that is due to cerebral hypoperfusion. Adding the cerebral hypoperfusion element sets syncope apart from other forms of TLOC, mostly epileptic seizures and psychogenic attacks. We provide short descriptions of different forms of syncope and other forms of TLOC.

[Syncope : epidemiology, definition, classification, pathophysiology and prognosis]. / Synkope : Epidemiologie, Definition, Klassifikation, Pathophysiologie und Prognose.

Syncope is a common clinical issue. Around 40 % of the total population experience syncope during their lifetime. Serious injuries and reduced quality of life are often observed after syncope. Furthermore, in some cases syncope can be associated with an unfavorable prognosis. Due to the complex etiology and pathophysiology, syncope provides challenges for doctors both in private and in clinical practices. This review is based on the latest European guidelines for syncope which were formulated by internists, neurologists, emergency physicians and cardiologists and gives an overview of the current epidemiology, definition, classification, pathophysiology and prognosis of syncope.

Clinical evaluation and risk stratification in patients with syncope.

Syncope accounts for approximately 1 % of visits to emergency departments. The first diagnostic step is to rule out nonsyncopal conditions as a cause of the transient loss of consciousness. Next, the basic clinical evaluation should identify patients at high risk for potentially life-threatening events. These patients should be admitted and monitored until a diagnosis is made and definitive treatment can be offered. Guided by the basic evaluation findings, specific tests should be performed to prove or rule out the suspected diagnosis. In low-risk patients, this should preferably be done in an outpatient setting. To date, there is no consensus on a structured algorithm for the evaluation of patients with syncope. Therefore, it seems beneficial to formulate an algorithm based on the current guidelines for the management of syncope for use in the clinical setting.