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Syncope: investigation and treatment
Satish R Raj1, Robert S Sheldon
1Faculty of Medicine, University of Calgary, Health Sciences Centre, 3330 Hospital Drive, NW, Calgary, Alberta, T2N 4N1, Canada. sheldon@ucalgary.ca
Insights
Diagnosing syncope often relies on patient history and physical exams, with cardiac syncope identifiable by specific historical features. Advances in ambulatory electrocardiography aid in diagnosing difficult syncope cases and understanding mechanisms.
Area of Science:
- Cardiology
- Neurology
Background:
- Syncope is a prevalent, disabling, and costly condition.
- Diagnosis frequently relies on clinical assessment, but specific historical features can differentiate causes.
- Cardiac syncope and vasovagal syncope require distinct diagnostic approaches.
Purpose of the Study:
- To review diagnostic strategies for syncope.
- To highlight the role of specific historical features in identifying cardiac syncope.
- To discuss advancements in ambulatory electrocardiography for syncope evaluation.
Main Methods:
- Review of recent reports identifying historical features suggestive of cardiac syncope.
- Evaluation of the utility of ambulatory electrocardiography, including implantable loop recorders.
- Analysis of therapeutic options for recurrent vasovagal syncope.
Main Results:
- Specific historical elements can distinguish cardiac syncope from vasovagal syncope and seizures.
- Implantable loop recorders are valuable for diagnosing challenging syncope cases and elucidating mechanisms.
- Effective therapies for clear dysrhythmias are established, but recurrent vasovagal syncope remains challenging.
Conclusions:
- A thorough history and physical examination are crucial for syncope diagnosis.
- Ambulatory electrocardiography has significantly improved syncope diagnosis and research.
- Ongoing trials will offer further guidance on managing recurrent vasovagal syncope with pharmacologic and non-pharmacologic treatments.
Abstract:
Syncope is a common condition that can be both disabling and expensive to treat. Although investigative modalities are sometimes required, a diagnosis can often be made with a good history and physical exam. Recent reports have identified specific historic features that are more suggestive of cardiac syncope as compared with vasovagal syncope and seizures. Advances in ambulatory electrocardiography (in particular the implantable loop recorder) have proven invaluable in both difficult-to-diagnose syncope, and in advancing our knowledge of its mechanisms. When clear dysrhythmias are manifest, appropriate therapies are self-evident. However, recurrent vasovagal syncope continues to be a condition that can be difficult to treat. Fortunately, there are well-conducted trials of both pharmacologic therapies (b-blockers, alpha agonists, and selective serotonin reuptake inhibitors) and nonpharmacologic treatments (orthostatic physical training and dual-chamber pacemakers) that should provide more guidance in the near future.