Syncope Etiology
Vasovagal Stimulant/psychogenic:
(most - Hyperadrenergic
common) response to stimulus
fear, physical stress,
intense emotion
Situational
(micturition/defecation):
- Hyperadrenergic
response to stretch
receptor stimulation of
bladder and rectum
Vasomotor instability:
- Common in elderly;
chronic illness (DM);
flushing, diaphoresis
w/o syncope
Orthostatic Underfilling of ventricles by
either poor venous return or
peripheral pooling upon
posture change
Dehydration
Drug effect (vasodilator -
antihypertensive)
Dysautonomia (ability to
increase sympathetic tone in
peripheral vessels upon
posture change due to primary
dysfunction in receptor or
discharge)
Cardiac 1. Arrhythmia (tachy/brady
syndrome; afib or
Clinical Presentation Diagnostic Therapy
Often preceded by stimulus Careful history and Benign: good
examination prognosis w/o
Brief prodrome of nausea or therapy
lightheadedness No structural or functional
abnormalities present B-blocker or anti-
Usually occurs in standing anxiety in high
posture Tilt table testing positive recurrences
(10-15%)
3 phases: initial rise in HR and Patient education
BP, subsequent profound drop in on avoidance and
BP, rapid recovery supine prevention
Sudden drop in systolic BP upon Careful history and Remove drugs
rising physical (screening for responsible
causes of fluid loss and
No prodrome medications) Volume expanders
(flourocortisone)
Usually occurs immediately after Valsalva maneuver
position change (but can occur Compression
much later) Screening tilt test stockings
Usually accompanied by tachy Tilt table test Alpha-agonists
(midodrine)
Serum norepi levels w/
position change
1. Palpitations precede; 1. ECG; Holter 1. Pacemaker
common in patients w/ monitoring; stress (pauses/bloc
 flutter; SVT; VT; sinus ischemic or myopathic test; event k); AA; ICD
pauses [>3sec]; cardiac conditions; monitoring; (life-
advanced AV block) profound brady (sick sinus electropysiologic threatening)
syndrome); frequent ectopy study
2. Valvular (AS, PS, 2. Surgery
severe MR) 2. 2. Echo; ECG; cardiac
cath 3. Address
3. Ischemia 3. Chest pain; dyspnea acute
preceding; common in high 3. ECG; serum episode;
4. Carotid Hypersensitivity risk for coronary disease cardiac enzymes; anticoagulati
(abnormally sensitive monitoring; cardiac on (possible
carotid body reflexes) 4. Syncope while shaving, cath thrombus)
tight collars, turning head;
5. CNS disorders older men 4. Careful carotid 4. Prevention
massage in supine
5. position 5. Anticoagulati
- Cerebrovascular on (vaso-
insufficiency (obstruction of 5. Careful history and occlusive);
vertebrobasilar arteries) physical; EEG; antianxiety
- Acute cerebral infarction or CT/MRI of brain (psychiatric);
hemorrhage (sudden onset (stroke); cerebral anticonvulsa
of neurologic dysfunction angiogram nts (seizure)
along w/ syncope) (vascular)
- Seizure (tonic/clonic
spasms; loss of
consciousness; period of
confusion/lethargy;
preceded by prodrome
- Psychiatric (hysteria no
signs of decreased BP or
perfusion; hyperventilation
anxiety, air hunger and
paresthesias w/o signs of
decreased BP or perfusion)