CME

Syncope in the Elderly

Weerasak Muangpaisan, M.D.
Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.

Siriraj Med J 2006; 58:

E-journal: http://www.sirirajmedj.com

yncope (transient loss

of consciousness) postural tone
3
1-6
80 65

1-3
26 syncope
syncope
5.9 4 syncope
1 4
syncope
syncope 5-6

syncope cerebral ischemia,

migraine, epileptic seizure,

( intermittent hydrocephalus, severe head
trauma, brain tumors intracerebral hemorrhage )

psychogenic seizure malingering
syncope
syncope mimic

syncope


ICU
syncope noncardiac cause 38 orthostatic hypotension, vasovagal response drug-induced 1
4 arrhythmia 50
cardiac cause cerebrovascular events seizure
2.2 1.7
3 1
syncope 7-12
syncope
2
Siriraj Med J, Volume 58, Number 9, September 2006

1. syncope
3

Arrhythmias
12.2
Heart block
4.1
Aortic stenosis
1.7
Myocardial infarction
1.7
Carotid sinus syndrome
2.4
Cardiac ischemia
0.1
Miscellaneous cardiac
1.9
Orthostatic hypotension
10.8
Vasovagal response
8.5
Drug-induced
3.9
Situational
2.4
Cerebrovascular event
2.2
Seizure
1.7
Postprandial hypotension
0.4
Miscellaneous
7.9
Unknown etiology
39.2

1. Cardiac cause
a. Cardiac arrhythmia syncope


structural heart diseases
atrial fibrillation, heart block sick sinus syndrome
arrhythmia
electrolyte imbalance,
anti-arrhythmics proarrhythmic effect digoxin,
anti-arrhythmics, vasodilators, inotropic agents, 2 agonist
tricyclic antidepressants prolonged QT interval torsade de pointes amiodarone,
beta-blocker Class I antiarrhythmic agents8-12
b. Obstruction of ventricular outflow tract
cardiac output cerebral perfusion
left ventricular outflow tract obstruction aortic stenosis degenerative process congenital bicuspid valve
hypertrophic obstructive cardiomy opathy (HOCM)
syncope right ventri1028

 2. syncope 7
( <35 )
(35-65 )
Neurally mediated:
Neurally mediated
Neurocardiogenic
Cardiac:
Psychiatric
Arrhythmic
(Hypertrophic cardiomyopathy) Mechanical
(WPW syndrome)
(Long QT syndrome)

(> 65 )
Cardiac
Arrhythmic
Mechanical
Orthostatic:
Drug induced
Neurally mediated
Carotid sinus hypersensitivity

cular outflow tract obstruction pulmonary embolism, myxoma, pulmonary stenosis pulmonary hypertension8
2. Neurally mediated syncope
a. Vasovagal syncope venous return
upright baroreceptor
aortic arch carotid sinus mechanore ceptor
ventricle ventricle
C-fibers medulla vagal efferent
vasodilatation hypotension13
b. Carotid sinus hypersensitivity asystole
3 / systolic blood pressure 50 . carotid sinus massage

8
c. Situational syncope peripheral mechanical receptors ventricular mechanical receptors

syncope8
3. Orthostatic hypotension systolic blood pressure 20 . diastolic blood pressure
10 . upright 3

multiple system strophy
diuretics
vasodilators

4. Postprandial hypotension
systolic blood pressure
20 . 20-120
splanchnic blood pooling
orthostatic hypotension

, autonomic neuropathy paraplegia, Parkinsons
disease, Alzheimers disease 8,14

5. Stroke syncope stroke

posterior circulation
focal neurological deficit brain stem signs ataxia,
vertigo, diplopia, dysarthria, hemiparesis unilateral numbness
6. Seizure syncope
transient loss of consciousness
2 3
7. Psychiatric disturbance syncope
hyperventilation, pseudoseizure

7,8,15

syncope

1. Prodromal symptoms
a. neurocardiogenic syncope

3. seizure, cardiogenic syncope, vasovagal syncope TIA

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Seizure

Cardiogenic syncope

1-2

cyanosis

EEG

Epileptiform pattern

Loss of tone

Diffuse slowing

Vasovagal
syncope

Diffuse slowing

TIA

Focal slowing

b.

c.

d.
e.

10 cardiac cause, micturition syncope, orthostatic hypotension

seizure vasovagal syncope
1-2
arrhythmia
arrhythmia supraventricular tachycardia
ventricular tachycardia
aura
convulsive syncope
pulmonary embolism, hyperventilation psychiatric associated syncope

2. Precipitating factors



a. left ventricular outflow tract obstruction, left ventricular dysfunction, ventricular arrhythmia
vagal response bradycardia
b. upright orthostatic hypotension
c. cardiac
arrhythmia
d.
carotid sinus hypersensitivity
e. 1-2
postprandial hypotension
f. situational syncope
g.
neurally mediated syncope
3.
a. seizure
10-15

b. syncope seizure
cyanosis
c. seizure syncope

4. Recovery phase
a. (amnesia)
syncope
2
cognitive impairment
syncope
b. sudden cardiac arrhythmia conduction block
Siriraj Med J, Volume 58, Number 9, September 2006

c. orthostatic hypotension neurocardiogenic syncope

d. neurally mediated syncope

e. neurological deficit stroke seizure

( Todds paralysis)
f. seizure
5.
a. silent myocardial infarction
cardiac arrhythmia autonomic neuropathy
orthostatic hypotension
b. cardiac arrhythmia HOCM, valvular disorders

c. syncope
neurally mediated syncope

d. cortical scar stroke, tumor,

head injury seizure
6.
a. vasodilatation volume depletion

b. bradycardia heart block

-blocker
c. arrhythmia antiarrhythmics, antidepressants, psychotropic drugs prolong QT interval polymorphic ventricular tachycardia
7,8
vital signs,
vital signs
( 5 )
upright systolic blood pressure 20 .
/ diastolic blood pressure 10 .
orthostatic hypotension
orthostatic hypotension
10
postprandial hypotension

orthostatic hypotension
structural heart disease
cardiac arrhythmia murmur
left ventricular outflow tract obstruction S3
S4 gallop congestive heart failure
neurological deficit
Todds paralysis
multiple system atrophy parkinsonism
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 carotid sinus massage (CSM) carotid sinus hypersensitivity carotid

bruit, 6
ventricular tachycardia, ventricular fibrillation
ICU monitor EKG
bifurcation internal external
carotid arteries 5 2
systolic blood pressure 50 . asystole 3


engorged neck vein
8,11,12,15,16,17
Electrocardiography (ECG) ECG 12 leads
syncope 5-10

Echocardiography noninvasive

ECG structural heart disease left ventricular dysfunction, dilated cardiomyopathy, HOCM, aortic
mitral valve diseases
Exercise stress testing syncope
catecholamine
ventricular tachycardia
rate-dependent atrioventricular block exercise
induced neutrally mediated syncope
Ambulatory continuous electrocardiography 24hour ECG syncope
ECG monitoring 17
syncope ECG monitoring 2
arrhythmia syncope syncope
ECG arrhythmia arrhythmia syncope syncope arrhythmia monitoring
arrhythmia syncope

Electrocardiography event and

memory loop ambulatory electrocardiogram recording
signal-averaged electrocardiography (SAECG)

1031

Invasive electrophysiologic studies (EP)

arrhythmia sinus node function, AV ventricular conduction arrhythmia
Tilt table testing noninvasive
syncope structural heart disease vasovagal
syncope
isoproterenol nitroglycerine
unexplained syncope
40-70
32-85 90

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1.
a. Syncope
b. Syncope
c. syncope

d. syncope

2. syncope
a. noncardiac cause
b. Arrhythmia cardiac cause
c. Cerebrovascular disease non
cardiac cause
d. Psychogenic cause
3.
(syncope)

Siriraj Med J, Volume 58, Number 9, September 2006

a.
b.
c.
d.

4. postprandial hypotension
a. nursing home
b. systolic blood pressure 20 .
15
c.
d. orthostatic hypotension
5. syncope
a. Anti-arrhythmic agents
b. Benzodiazepine
c. Tricyclic antidepressants
d. Diuretics

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