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The clinical approach to

Department of Cardiology
Liverpool Hospital
Who is she?
A State Government minister has fallen victim to a
fainting spell during a press conference and had to sit
down to recover.

Gaming and Racing Minister Graham West was

announcing details of a review into the thoroughbred
racing industry when he took reporters by surprise by
almost fainting and having to take a seat.

After highlighting the government's key initiative, Mr

West asked for a glass of water.

While fielding questions from the media, he asked for a

break in proceedings and began to tip backwards but
was caught, then given a seat and a glass of water by
his minders.
Asked later about his health, Mr West dismissed

"I think it's dehydration," he said.

"Most of yesterday I was on the road and I need to take

better care of myself."

"He did not faint, he felt faint," Mr Guilbert-Wright said.

"He had probably four or five hours sleep, probably

hasn't eaten properly.

"He just decided to sit down, he probably went a bit


 Transient loss of consciousness and postural

tone with spontaneous recovery
 Transient
 Loss of consciousness
 Postural tone
 Spontaneous recovery, how long ?
 Complete recovery
 As if nothing has happened!!

 A symptom
 Not a disease !
Underlying mechanism of
 Decrease in the global perfusion to the
brain, especially the brain stem
 ARAS (ascending reticular activating
– Responsible for arousal
 Cessation of blood flow to the brain
will lead to loss of consciousness
What are the key
components responsible to
ensure adequate perfusion
of the brain?
 Adequate blood volume
 Adequate perfusion pressure
 Adequate pump
 Humans are at a disadvantage compared
to most 4 legged animals!!
What are the key components
of an adequate pump?
 To ensure adequate throughput
 Adequate rate
 Too slow
 Too fast
 Adequate pump function – adequate
 The pump is not obstructed
 How about conduit construction?
Conduit obstruction

 Vascular supply of the brain

 Circle of Willis
 Obstruction of one of the arteries eg
carotid stenosis does not cause
Loss of postural tone

 Occur when patients are upright

 Why?
 Seldom occurs when patients are lying
Spontaneous recovery

 Why ?
 Not syncope if no spontaneous
 Why ?
 No residual focal neurological deficit
Reported frequency of
 Individuals < 18 years
– 15%
 Military population 17 – 46 years of
– 20 – 25%
 Individuals 40 – 59 years of age
– 16 – 19%
 Individuals > 70 years of age
– 23%
Causes of syncope

 Vascular
 Cardiac
 Neurogenic
 Metabolic/miscellaneous

 Postural
– Drug induced
– Hypovolumia
– Autonomic failure
 Reflex mediated
– Vasovagal
– Situational (cough, micturition,
– Carotid sinus hypersensitivity

 Anatomical
– Obstruction
– Aortic stenosis
– Hypertrophic cardiomyopathy
– Atrial myxoma

 Arrhythmia
– Bradyarrhythmia
– Tachyarrhythmia
Causes of syncope

 Neurogenic
 Miscellaneous
Approach to syncope

 History is very important

 The circumstance in which it happened
 Distinguish from other situation where
there is
– Altered consciousness
 Physical examination
Physical examination

 Signs of hypovolumia
 Blood pressure
 Postural drop
 Heart rate
 Heart sounds
 Murmurs
 Carotid sinus message

 Arrhythmia
 Not always present when you do the
 Look for evidence that it happened
 Look for substrate for arrhythmias
 Look for consequences of underlying
 Exclude treatable causes

 Brady – arrhythmia
 Tachy - arrhythmia
Normal impulse formation
and propagation in the
Origin of the waves –
electrical activities
ECG waveform
Orientation of limb leads
Orientation of chest leads
Heart is too slow

 SA node disease
– Sinus bradycardia
– Sinus arrest
– Sino-atrial block
– Carotid sinus hypersensitivity
 AV node disease
– 1st, 2nd, 3rd degrees of AV block
– Bundle branch block does not cause bradycardia
Heart rate is too fast

 Sinus tachycardia
 Supraventricular tachycardia
 Ventricular tachycardia
 Narrow complex tachycardia
 Broad complex tachycardia
Cardiac causes

 Aortic stenosis
 Hypertrophic cardiomyopathy

 Diagnose structural heart disease

 A normal echo does not exclude
cardiac causes
Other investigations

 Holter monitoring
 Event monitors
 Implantable event recorders
 Tilt table test
 Signal average ECG
 Electrophysiologic studies
 Cardiac catheterisation

 Underlying cause

 Depends on underlying causes

 Recurrence is common