Benign Syncope Research Articles

Syncope

Key Points Most cases of pediatric syncope occur in adolescence and are benign, either neurally mediated syncope (also known as vasovagal or neurocardiogenic syncope) or orthostatic hypotension. In early childhood (6 months to 3 years) syncopal episodes typically result from breath-holding spells, either cyanotic or pallid. A detailed history is most crucial in distinguishing benign syncope from less common but more serious episodes, particularly cardiac- induced syncope or seizures. All patients with syncope need close follow-up to monitor for frequency of episodes and response to any therapeutic interventions.

Differential diagnostics of unclear syncope

The clarification of syncope is adiagnostic challenge as possible causes often occur only intermittently. Therefore, adetailed and standardized anamnesis is essential as it 1)differentiates syncope from other transient losses of consciousness (TLOC) and 2)directly clarifies possible causes of syncope. The risk stratification plays acentral and very important role in order to avoid unnecessary examinations in patients with benign syncope and to provide patients with life-threatening, mostly cardiac syncopal episodes with timely diagnostics and treatment. In cases where the cause of syncope is still unclear, astandardized approach is indicated using extended diagnostics, such as atilt table examination, acarotid sinus pressure test, prolonged telemetric monitoring or clarification with an implantable loop recorder (ILR).

Lack of Utility in Performing Blood Glucose Measurement and Electrocardiogram in the Outpatient Evaluation of Benign Pediatric Syncope.

We aimed to determine the frequency of blood glucose and electrocardiogram (EKG) abnormalities in previously healthy children who present to an emergency department (ED) with a diagnosis of benign syncope. Chart review of consecutive children aged 5 to 18 years presenting to the pediatric ED from 2004 to 2014 with a discharge diagnosis of benign syncope was done. Of 969 patients, hypoglycemia (serum glucose <60 mg/dL) was present in only 3 cases (0.3%). Of 754 patients with EKG performed, only 4 cases (0.6%) was an abnormality requiring further cardiac evaluation identified; cardiac echocardiogram was performed in 3 of these 4 patients, which revealed no cardiac pathology. Financial analysis for performing blood glucose measurement and EKG on these patients amounted to total health care cost of $222 526. We concluded that previously healthy children with syncope rarely have hypoglycemia or underlying cardiac abnormality. The routine performance of tests can incur significant health care expenditure.

Implantable Loop Recorder in Inherited Arrhythmia Diseases

The differential diagnosis between benign syncope common in a young population and life-threatening arrhythmic ones represents a major challenge in the management of patients with inherited arrhythmias (IAs) [(1)][1]. In this population, ventricular arrhythmias can often be hemodynamically tolerated

Etiological diagnosis, prognostic significance and role of electrophysiological study in patients with Brugada ECG and syncope

BackgroundSyncope is considered a risk factor for life-threatening arrhythmias in Brugada patients. Distinguishing a benign syncope from one due to ventricular arrhythmias is often difficult, unless an ECG is recorded during the episode. Aim of the study was to analyze the characteristics of syncopal episodes in a large population of Brugada patients and evaluate the role of electrophysiological study (EPS) and the prognosis in the different subgroups. Methods and resultsOne hundred ninety-five Brugada patients with history of syncope were considered. Syncope were classified as neurally mediated (group 1, 61%) or unexplained (group 2, 39%) on the basis of personal and family history, clinical features, triggers, situations, associated signs, concomitant therapy. Most patients underwent EPS; they received ICD or implantable loop-recorder on the basis of the result of investigations and physician's judgment. At 62±45months of mean follow-up, group 1 showed a significantly lower incidence of arrhythmic events (2%) as compared to group 2 (9%, p<0.001). Group 2 patients with positive EPS showed the highest risk of arrhythmic events (27%). No ventricular events occurred in subjects with negative EPS. ConclusionEtiological definition of syncope in Brugada patients is important, as it allows identifying two groups with different outcome. Patients with unexplained syncope and ventricular fibrillation induced at EPS have the highest risk of arrhythmic events. Patients presenting with neurally mediated syncope showed a prognosis similar to that of the asymptomatic and the role of EPS in this group is unproven.

Temporal Trends in Utilization of Transthoracic Echocardiography for Common Outpatient Pediatric Cardiology Diagnoses over the Past 15 Years

No data exist regarding the temporal trends in utilization of transthoracic echocardiography (TTE) in an outpatient pediatric cardiology setting. This study evaluates the trends in utilization of TTE for common diagnoses known to have low diagnostic yield and the factors influencing these trends. Patients evaluated at our pediatric cardiology clinics from January 2000 to December 2014 and discharged with final diagnoses of innocent murmur, noncardiac chest pain, benign syncope, and palpitations were included. Variables collected retrospectively included patient age, sex, insurance type, distance from clinic, and ordering physician's years of experience since fellowship. Of the 74,881 patients seen by 35 physicians, 36,053 (48.1%) had a TTE. The TTE rates increased from the beginning of 2000 to the end of 2004 (5.2% per year; P<.001) and then steadily declined until the end of 2014 (1.6% per year; P<.001). Utilization for noncardiac chest pain remained the highest, and use in infants increased significantly during the study period (P<.001). After adjusting for all other factors, the following variables were associated with higher TTE utilization: younger age, males, Medicaid insurance, increased distance from clinic, and being seen by less experienced physicians. Temporal trends persisted after adjusting for all these factors. After an initial surge in TTE utilization from 2000 to 2004, there was a steady decline. This study identifies some important factors influencing these trends. This information could help design quality interventions, but additional factors need to be explored since the trends persist despite adjusting for these factors.

A New Technique for Jaw Thrust in Unconscious Craniofacial Trauma Patients

The loss of consciousness is one of the commonly encountered emergency situations in maxillofacial trauma patients. Apart from benign syncope, there are other causes for unconsciousness. Majority of these patients have intact respiratory muscle activity, but the airway patency is compromised due to airway obstruction by tongue fall back. Traditionally head tilt-chin lift and jaw thrust techniques were employed to maintain patency of the airway. Head tilt-chin lift technique involves tilting the head backward and thus is dangerous in case of suspected cervical spine injury in trauma cases. Jaw thrust is an efficient method and can be performed in cervical spine injury cases. But it requires continuous forward pull on mandible till the time patient regains consciousness; which is physically strenuous for rescuer. The purpose of this article is to present a new technique for jaw thrust which is based on similar principle of traditional jaw thrust. The advantage is that, jaw thrust can be maintained for an extended time period in these patients.

Influence of passive leg movements on blood circulation on the tilt table in healthy adults

BackgroundOne problem in the mobilization of patients with neurological diseases, such as spinal cord injury, is the circulatory collapse that occurs while changing from supine to vertical position because of the missing venous pump due to paralyzed leg muscles. Therefore, a tilt table with integrated stepping device (tilt stepper) was developed, which allows passive stepping movements for performing locomotion training in an early state of rehabilitation. The aim of this pilot study was to investigate if passive stepping and cycling movements of the legs during tilt table training could stabilize blood circulation and prevent neurally-mediated syncope in healthy young adults.MethodsIn the first experiment, healthy subjects were tested on a traditional tilt table. Subjects who had a syncope or near-syncope in this condition underwent a second trial on the tilt stepper. In the second experiment, a group of healthy subjects was investigated on a traditional tilt table, the second group on the tilt ergometer, a device that allows cycling movements during tilt table training. We used the chi-square test to compare the occurrence of near-syncope/syncope in both groups (tilt table/tilt stepper and tilt table/tilt ergometer) and ANOVA to compare the blood pressure and heart rate between the groups at the four time intervals (supine, at 2 minutes, at 6 minutes and end of head-up tilt).ResultsSeparate chi-square tests performed for each experiment showed significant differences in the occurrence of near syncope or syncope based on the device used. Comparison of the two groups (tilt stepper/ tilt table) in experiment one (ANOVA) showed that blood pressure was significantly higher at the end of head-up tilt on the tilt stepper and on the tilt table there was a greater increase in heart rate (2 minutes after head-up tilt). Comparison of the two groups (tilt ergometer/tilt table) in experiment 2 (ANOVA) showed that blood pressure was significantly higher on the tilt ergometer at the end of head-up tilt and on the tilt table the increase in heart rate was significantly larger (at 6 min and end of head-up tilt).ConclusionsStabilization of blood circulation and prevention of benign syncope can be achieved by passive leg movement during a tilt table test in healthy adults.