How is cardiac syncope treated

At asyncope(Synonyms: general collapse; blackout; Gowers syndrome; cardiac syncope; cardiac syncope; collapse; short-term loss of consciousness; fainting; fainting; fainting syndrome; sympathicovasal seizure; syncopal seizure; syncope; syncope with vasoconstriction; fainting caused by vagus vasoconstriction; fainting from the vagus; Phenomenon; vasovagal syncope; vasovagal seizure; vasovagal reflex; vasovagal phenomenon; vasovagal syndrome; ICD-10-GM R55: syncope and collapse) it is a short-term loss of consciousness ("transient loss of consciousness", TLoC) caused by a reduced perfusion (Reduced blood flow) of the brain and is usually associated with a loss of muscle tone.

A reduction in the systemic blood pressure values ​​of <60 mm Hg lasting approx. 6-8 seconds is sufficient for syncope, i.e. H. an attack-like loss of consciousness comes.

A Presyncope is defined according to the S1 guideline as follows: "Prodromal stage (precursor symptoms) of syncope with dwindling of the senses (black vision, soft hearing), possibly with sweating and pronounced hyperventilation (increased breathing that goes beyond what is required). Does not have to go into a Open syncope ".

The brief loss of consciousness("Transient loss of consciousness", TLoC) is defined according to the guideline of the European Society of Cardiology (ESC) [guidelines: 4] as follows:

  • short duration (<5 min)
  • abnormal motor control
  • occasional lack of response to speech or stimuli
  • Amnesia (loss of memory) for the duration of unconsciousness

In syncope, one can distinguish the following forms:

  • orthostatic syncope (approx. 20% of all syncope) - syncope as part of the change from a lying, sitting or kneeling position to an upright position
  • cardiogenic syncope/ cardiac syncope (approx. 20%) - syncope affecting the heart
    • rhythmogenic syncope (syncope due to cardiac arrhythmias)
    • vasovagal syncope (VVS; synonym: reflex syncope; approx. 45%): z. B.
      • orthostatic vasovagal syncope (orthostatic VVS); Trigger: standing still for a long time; often also narrow or stuffy rooms
      • Syncope in hypersensitive carotid sinus; Trigger: Pressure on carotid sinus
      • Blood / injury associated vagal syncope; Triggers: Injuries, seeing blood, sudden pain
      • Syncope with certain stimuli; Trigger: e.g. B. Swallowing, micturition (urination)
  • Syncope through a Valsalva maneuver (approx. 10%; forced expiration (exhalation) against the closed mouth and nostril opening with simultaneous use of the abdominal press)
  • neurogenic syncope (approx. 5%) - syncope affecting the nervous system
  • metabolic syncope (approx. 3%) - syncope due to a metabolic disorder
  • psycho-vegetative syncope (approx. 1%)
  • systemic / drug-induced syncope (14.5%)
  • unclear syncope

TheESCGuideline know three categories of syncope [5, guidelines: 2]:

  • Reflex syncopation (vasoval syncope) - Brief loss of consciousness due to excessive vagal tone; The causes are manifold:
    • emotionally induced syncope (experiences of shock or pain: mainly due to blood / injury associations)
    • neurocardiogenic syncope (physical stressful situations: e.g. after standing for a long time)
    • Carotid sinus syncope (through massage on the carotid sinus)
    • visceral reflexes (visceral syncope) during defecation (defecation), micturition (bladder emptying; micturition syncope) or the swallowing process (visceral reflex syncope)
    • Syncope without recognizable triggers
  • Syncope due to orthostatic hypotension (pathological drop in blood pressure when standing up) (synonyms: orthostatic dysregulation; orthostatic hypotension, orthostatic circulatory regulation disorder)
  • Cardiac syncope - cardiac syncope
    • rhythmogenic syncope - brief loss of consciousness as a result of a cardiac arrhythmia
      • bradycardiac arrhythmias: sick sinus syndrome, AV blockages 2nd and 3rd degree
      • tachycardia cardiac arrhythmias: supraventricular tachycardias, ventricular tachycardias / ventricular fibrillation (e.g. after myocardial infarction, ion channel diseases such as Brugada syndrome or long QT syndrome [Romano-Ward syndrome])
    • Mechanical causes (cardiovascular syncope): e.g. B. symptomatic aortic stenosis

Syncope can be a symptom of many diseases (see under "Differential Diagnoses").

A further cause has now been identified as a gene on chromosome 2q32.1: Carriers of this gene have an increased risk of suddenly and unexpectedly fainting, from which they usually wake up a short time later. Homozygous carriers of this variant had a 30% increased risk of developing syncope in the course of their life [8].

Gender ratio: In childhood, girls are more often affected than boys.

Frequency peak: The symptom occurs particularly in older people, but syncope can also affect children, especially between the ages of 12 and 19. Around 15% of all children until adulthood suffer from syncope at least once [3, 4].

Young people only have in exceptional casescardiac ("heart-related") Syncopewhose share increases significantly at the latest from one Age> 65 years at.

Approx. 3-5% of patients in an emergency room show the main symptom "syncope".

The Prevalence (Frequency of illness) is included 6 % of all elderly people (in Germany). Neurogenic syncope can be observed here most frequently, followed by the circulatory-related and those caused by cardiac arrhythmias.

Young people only have in exceptional casescardiac syncopewhose share increases significantly at the latest from one Age> 65 years at.

Course and prognosis: The onset is usually sudden and is characterized by spontaneous (on its own) and complete recovery.

The following questions need to be clarified immediately: Is it a syncope (see above) or is the short-term unconsciousness caused by other serious disorders? Has there been a life-threatening event? Are there any consequences of the fall that require treatment?

Note: The evaluation of syncope should begin immediately in an emergency room. The aim is to determine as quickly as possible whether there is a low or a high risk of cardiogenic (heart-related) and thus potentially life-threatening syncope (recommendation grade I) [current ESC guidelines].
Arrhythmias (Cardiac arrhythmias) usually occur shortly after fainting. In low-risk patients (CSRS, Canadian Syncope Risk Score), half of the serious arrhythmias became apparent within 2 hours of admission to the emergency room; in medium and high risk patients within 6 hours; 3.7% of patients with syncope are arrhythmic within one month after syncope [7].

Syncope (35%), followed by angina pectoris ("chest tightness"; sudden pain in the heart region) / chest pain (chest pain) (11.9%) and cardiac complaints (23%) are the most common emergencies on board airliners Emergency there [1].

The incidence rate (frequency of new cases) after syncope in a traffic accident involving cars, trucks or motorcycles and thus receiving medical care was 20.6 per 1,000 person-years (PY), almost twice as high as in the general population with 12 , 1 / 1,000 PJ [2].

In patients with syncope who were not known to have cardiovascular disorders, increased after syncope of unknown cause the frequency of atrial fibrillation (AF) by 84%, future coronary events by 85%, aortic valve stenosis (narrowing of the outflow tract of the left ventricle) 106% and heart failure (cardiac insufficiency) by 124%. The mortality (number of deaths in a certain period of time, based on the number of the population concerned) was 22% higher and the cardiovascular mortality 72% higher [6].
At a Syncope due to orthostatic hypotension (abnormal drop in blood pressure when standing up) the incidence of heart failure (cardiac insufficiency) was increased by 78%, that of atrial fibrillation (AF) by 89% and the total mortality by 14%. The risk of having an apoplexy (stroke) increased by 66% [6].

Symptomatic high risk patients require further diagnostics immediately and should then be treated as an inpatient.
Asymptomatic high risk patients can be discharged promptly in the case of unclear syncope with a low risk and continued on an outpatient basis. For the definition of asymptomatic high-risk patients see under "Further therapy".

literature

  1. Donaldson E, Pearn J: First aid in the air. Aust N Z J Surg 1996; 66: 431-434
  2. Numé AK et al .: Syncope and Motor Vehicle Crash Risk. A Danish Nationwide Study. JAMA Intern Med 2016, online February 29; doi: 10.1001 / jamainternmed.2015.8606
  3. Colman N, Nahm K, Ganzeboom KS et al .: Epidemiology of reflex syncope. Clinical autonomic research: official journal of the Clinical Autonomic Research Society 2004; 14 Suppl 1: 9-17
  4. Wieling W, Ganzeboom KS and Saul JP: Reflex syncope in children and adolescents. Heart 2004; 90: 1094-1100
  5. Moya A, Sutton R, Ammirati F, Blanc et al .: for the Task Force for the Diagnosis and Management of Syncope; European Society of Cardiology (ESC); European Heart Rhythm Association (EHRA); Heart Failure Association (HFA); Heart Rhythm Society (HRS): Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009; 30: 2631-71. Epub 2009 Aug 27.
  6. Yasa E et al .: Cardiovascular risk after hospitalization for unexplained syncope and orthostatic hypotension. Heart 2017 Aug 3. pii: heartjnl-2017-311857. doi: 10.1136 / heartjnl-2017-311857
  7. Thiruganasambandamoorthy V et al .: Duration of Electrocardiographic Monitoring of Emergency Department Patients with Syncope. Circulation 2019: 0 Originally published 21 Jan 2019 https://doi.org/10.1161/CIRCULATIONAHA.118.036088
  8. Hadji-Turdeghal K et al .: Genome-wide association study identifies locus at chromosome 2q32.1 associated with syncope and collapse Cardiovascular Research, cvz106, https://doi.org/10.1093/cvr/cvz106 Published: 03 May 2019

Guidelines

  1. Moya A, Sutton R, Ammirati F, Blanc et al .: for the Task Force for the Diagnosis and Management of Syncope; European Society of Cardiology (ESC); European Heart Rhythm Association (EHRA); Heart Failure Association (HFA); Heart Rhythm Society (HRS): Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009; 30: 2631-71. Epub 2009 Aug 27.
  2. Brignole M, Moya A, de Lange F et al .: 2018 ESC Guidelines for the diagnosis and management of syncope. European Heart Journal, ehy037, https://doi.org/10.1093/eurheartj/ehy037 Published: 19 March 2018
  3. S1 guideline: syncope. (AWMF registration number: 030-072), January 2020 long version
  4. S2k guideline: syncope in children and adolescents. (AWMF registration number: 023-004), February 2020 long version

     
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