Differential Diagnosis Of Syncope Research Articles

Abstract 13381: Syncope as a Presentation of Waldenstrom Macroglobulinemia

Syncope as defined by ACC/AHA is defined as a symptom that presents with an abrupt, transient, complete loss of consciousness, associated with inability to maintain postural tone with rapid and spontaneous recovery without clinical features of other non-syncope causes of loss of consciousness, such as seizure, antecedent head trauma, or apparent loss of consciousness. Syncope is a common complaint treated in the emergency department and a major reason for hospital admissions. A rare etiology to this common symptom is Waldenstrom macroglobulinemia. Case: A 49-year-old man presented to the emergency department, referred for hypercalcemia. On review of records, the patient was noticed to have been seen previously in emergency visits for two episodes of syncope and recurrent anemia. The laboratory studies at the time of admission were remarkable for hemoglobin of 7.3, WBC of8.32, hematocrit of 28.5, MCV 77.2, platelets of 124,000. Complete metabolic panel showed a total protein of 13.1, calcium of 11.2 with an albumin of 1.6 and corrected sodium of 117. EKG demonstrated a sinus rhythm with left atrial enlargement and nonspecific T wave abnormalities. Echocardiogram demonstrated a LVEF of 60-65% with normal LV wall motion, posterior wall thickness, and septal wall thickness with grade 1 diastolic dysfunction. CT of the head was unremarkable. Further work up for recurrent microcytic anemia. Bone marrow biopsy was obtained which demonstrated a Waldenstrom macroglobulinemia. Further follow up revealed that the patient has not had any other syncopal episodes since initiation of treatment. Conclusion: Although current literature suggests a broad differential diagnosis for the symptom of syncope, Waldenström macroglobulinemia remains a rare etiology of syncope with an estimated incidence of 1000 to 1500 cases diagnosed per year. Waldenstrom macroglobulinemia can cause hyperviscosity syndrome in about 30 percent of the population with Waldentroms, which when severe and coupled with anemia and plasma volume expansion has been reported as arare cause of syncope. Syncope evaluation should be detailed with history and physical examination and hyper-viscosity syndromes, a medical emergency, should be considered as differential diagnosis of syncope.

The Role of Adenosine and Its Degradation Enzymes – Adenosinedeaminase and Adenosinekinase in Pathogenesis of Vasovagal Syncope

IntroductionAdenosine is mediator regulating physiological and pathological processes in organism. It probably plays a role in pathogenesis of vasovagal syncopes (VVS), too. Adenosine, its receptors and degradation enzymes– adenosinedeaminase (ADA) and adenosinekinase (ADK), are called the adenosinergic system. AimWe aimed to evaluate serum levels of adenosine, ADA and ADK in patients with tilt-induced VVS and compare them to tlit-negative controls. Secondary aim was to compare the levels between the types of VVS and correlate them with hemodynamic parameters. Subjects and methodsAltogether 132 individuals were involved in this study (age 39,88±15,64 years, 51 males). All patients underwent head up tilt test (HUTT) in differential diagnosis of syncope. Blood sampling was performed before and after HUTT. Baseline and stimulated serum levels of adenosine, ADA and ADK were evaluated by ELISA method. ResultsHUTT was positive in 91 patients (HUTT+), 41 individuals were negative (HUTT-). HUTT+ patients had higher baseline and stimulated adenosine levels, when compared to HUTT- population. The rise in adenosine was higher in HUTT+ group. On the other hand, the increase of ADA was significantly higher in HUTT- subjects. Among HUTT+ group, the highest adenosine was found during vasodepressoric VVS. ConclusionAdenosinergic system may play role in pathogenesis of VVS. Patients with VVS have higher adenosine levels, that may be caused by attenuated degradation. Adenosine seems to be involved predominantly in vasodepressoric type of VVS. Further research evaluating complex function of adenosinergic system in these patients is needed.

Clinical features of vestibular syncope associated with tumarkin attacks in delayed endolymphatic hydrops

Objective: To analyze the clinical characteristics of vestibular syncope (VS) associated with drop attacks (DA) in delayed endolymphatic hydrops (DEH). Methods: DEH cases with complete data were retrospectively analyzed, including three DEH cases with DA and VS (VS group), and six DEH cases without DA or VS (control group). The clinical profile, the results of neurotological examinations [such as pure tone audiometry, electrocochleography (EcochG), caloric test, vestibular evoked myogenic potentials (VEMP), and video head impulse test (vHIT)] and treatment outcomes were analyzed. Results: (1) In the VS group, there were three cases of ipsilateral DEH; in the control group, there were six cases of ipsilateral type. One case in each group had a history of migraine. (2) The prevalence of abnormal results in caloric test, vHIT, cervical VEMP, and ocular VEMP in the VS group was 3/3, 1/3, 2/2, and 2/2, respectively, and in the control group was 3/6, 0/3, 1/6, and 4/6, respectively. Two cases in each group underwent EcochG, and no identifiable waveform was elicited on the affected side, and-SP/AP ratio of unaffected side was less than 0.4. (3) Patients in both groups were initially treated with conservative medication. Two cases in the VS group subsequently received intratympanic injections of dexamethasone. No DA or VS occurred during a follow-up period lasting over one year. All patients achieved good control of vertigo during the follow-up period. Conclusions: VS may occur in the patients with DEH. The differential diagnosis of syncope in patients with otogenic vertiginous disease can help improve clinical diagnosis and treatment.

Coronary vasospasm-induced syncope with dynamic changes of regional wall motion abnormalities confirmed real-time: a case report.

BackgroundCoronary vasospasm is primarily characterized by transient and reversible vasoconstriction causing myocardial ischaemia and can manifest with various clinical features, including syncope.Case summaryA 50-year-old man presented with recurrent episodes of syncope for 3 days. The last syncope history occurred during an early morning walk, accompanied by dizziness and loss of consciousness. There was no clear history of chest pain at the time. He smoked one pack of cigarettes daily and frequently consume alcohol. Approximately 3 h after admission, echocardiography initially revealed normal systolic function; however, during the examination, the patient suddenly complained of dizziness and regional wall motion abnormalities (RWMA) of the left anterior descending artery (LAD) territory were observed. Both RWMA and dizziness spontaneously improved within a few minutes. Emergency coronary angiography (CAG) was performed to confirm vasospasm. Coronary angiography revealed mild atherosclerosis of proximal LAD. After 3 min, he complained of dizziness and vague chest discomfort, and electrocardiogram revealed ST-segment elevation. We immediately performed angiography of the left coronary artery, and CAG revealed total occlusion of the proximal LAD without any provocation. After administration of intracoronary nitroglycerine, coronary flow was restored completely and ST-segment deviation normalized along with relief in chest discomfort. The patient’s symptoms have not recurred for 3 months while being on calcium channel blocker and long-acting nitrates.DiscussionCoronary vasospasm can present as transient and dynamic myocardial ischaemia along with angina. Coronary vasospasm should always be considered in the differential diagnosis for syncope.

36-year-old Male with Syncope.

Case PresentationA 36-year-old incarcerated male presented to the emergency department (ED) after an episode concerning for syncope. The patient had nystagmus and ataxia on initial examination.DiscussionThere is a broad differential diagnosis for syncope, and for patients presenting to the ED we tend to focus on cardiogenic and neurologic causes. This case takes the reader through the differential diagnosis and systemic work-up of a patient presenting to the ED with syncope.

Case with Cardiovascular Causes in the Differential Diagnosis of Syncope

Case with Cardiovascular Causes in the Differential Diagnosis of Syncope

Sudden Death by Catecholaminergic Polymorphic Ventricular Tachycardia in Children

Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT) is a severe cardiac arrhythmogenic hereditary illness, which affects children and young adults with a structurally healthy heart. Its prevalence is of one case in 10 thousand inhabitants. It is a potentially fatal illness, part of the differential diagnosis of syncope in children. The present study has the purpose of relating the case of a child that, during the investigation of convulsive syncope, presented sudden death aborted due to CPVT and to describe the diagnosis difficulties of the case, comparing with data from the literature

Morte Súbita por Taquicardia Ventricular Polimórfi ca Catecolaminérgica em Criança

A taquicardia ventricular polimórfi ca catecolaminérgica (TVPC) é uma doença cardíaca arritmogênica grave, hereditária, que acomete crianças e adultos jovens com coração estruturalmente normal. Sua prevalência é de um caso em 10 mil habitantes. É uma doença potencialmente fatal, que faz parte dos diagnósticos diferenciais de síncope em criança. O presente trabalho tem como objetivo relatar o caso de uma criança que, durante investigação de síncope convulsiva, apresentou morte súbita abortada devido à TVPC e abordar as difi culdades diagnósticas do caso, comparando com dados da literatura.

School Nurses on the Front Lines of Medicine: The Approach to a Student After a Syncopal Event: Don’t “PASS OUT”

Students presenting with syncope and/or seizure occur occasionally in the school setting. Several studies have shown that seizures as well as respiratory distress are the most common medical emergencies that prompt school nurses and staff to contact emergency medical services (EMS) to transport students to the closest emergency department (Knight 1999, Olympia 2005). It is important to develop a differential diagnosis for syncope, to initiate stabilization of the student with life-threatening symptoms, and to triage these students to an appropriate level of care (back to the classroom, home with their guardian with follow-up at their primary health care provider's office, or directly to the closest emergency department via EMS). This article describes the initial assessment and management of two students presenting after syncopal events.

Structural heart disease as the cause of syncope.

We described the clinical evolution of patients with structural heart disease presenting at the emergency room with syncope. Patients were stratified according to their syncope etiology and available scores for syncope prognostication. Cox proportional hazard models were used to investigate the relationship between etiology of the syncope and event-free survival. Of the 82,678 emergency visits during the study period, 160 (0.16%) patients were there due to syncope, having a previous diagnosis of structural heart disease. During the median follow-up of 33.8±13.8 months, mean age at the qualifying syncope event was 68.3 years and 40.6% of patients were male. Syncope was vasovagal in 32%, cardiogenic in 57%, orthostatic hypotension in 6%, and of unknown causes in 5% of patients. The primary composite endpoint death, readmission, and emergency visit in 30 days was 39.4% in vasovagal syncope and 60.6% cardiogenic syncope (P<0.001). Primary endpoint-free survival was lower for patients with cardiogenic syncope (HR=2.97, 95%CI=1.94-4.55; P<0.001). The scores were analyzed for diagnostic performance with area under the curve (AUC) and did not help differentiate patients with an increased risk of adverse events. The differential diagnosis of syncope causes in patients with structural heart disease is important, because vasovagal and postural hypotension have better survival and less probability of emergency room or hospital readmission. The available scores are not reliable tools for prognosis in this specific patient population.

Should We Regularly Include Pulmonary Embolism in the Differential Diagnosis of Syncope?

Synopsis: In patients admitted to the hospital for a first episode of syncope, workup for pulmonary embolism should be included, despite alternative explanations for the syncopal episode. Pulmonary embolism was identified in nearly 1 of every 6 patients hospitalized for syncope. Source: Prandoni P, Lensing AW, Prins MH, et al. Prevalence of pulmonary embolism among patients hospitalized for syncope. N Engl J Med. 2016;375:1524–1531.

RECURRENT SYNCOPE AS A PRESENTATION OF SYSTEMIC MASTOCYTOSIS

Syncope is one of the most common referrals to the cardiology clinic. Obtaining a detailed history is paramount when evaluating the broad differential diagnosis for syncope. We describe a case of recurrent syncope caused by systemic mastocytosis diagnosed after taking a careful history. A 47-year-

Significance of the Calgary Syncope Seizure Scores and the Modified Calgary Syncope Seizure Scores for differential diagnosis of syncope or epilepsy in children

Objective To analyze the significance of the Calgary Syncope Seizures Scores (CSSS) and the Modified Calgary Syncope Seizure Scores(MCSSS) for differential diagnosis of syncope or epilepsy in children. Methods Totally 201 children[95 male, and 106 female, aged 5-18 years, mean age (11.76±3.03) years] with syncope or epilepsy who visited the syncope clinic or admitted to the Department of Nerve Specialty Clinic of Pediatrics, the Second Xiangya Hospital of Central South University from October 2013 to April 2014 were included in the study.Patients were eligible if they had ≥1 loss of consciousness.The diagnosis was analyzed by the CSSS and the MCSSS and receiver operating characteristic (ROC) curve was used to explore the predictive value of different scores in differential diagnosis of syncope or epilepsy in children. Results There were significant differences in the CSSS between syncope[-4(-6, 1)] and epilepsy[2(-3, 5)] in children(Z=-11.63, P<0.01). When the score was ≥1, the sensitivity and specificity of the differential diagnosis between syncope and epilepsy were 91.46% and 95.80%, respectively; and Youden index was 0.87.Epilepsy should be considered when the score was ≥1.There were significant differences in the MCSSS between syncope[-4(-6, 1)] and epilepsy[3(-3, 6)] in children(Z=-11.71, P<0.01). When the score was ≥1, the sensitivity and specificity of the differential diagnosis between syncope and epilepsy were 92.68% and 96.64%, respectively; and Youden index was 0.89.Epilepsy should be considered when the score was ≥1. Conclusions CSSS and MCSSS might be used as an initial diagnostic method in differential diagnosis between syncope and epilepsy in children, based on the history of the patients.MCSSS in the differential diagnosis between syncope and epilepsy in children was more objective, easier to operate in the clinical work than CSSS. Key words: Calgary score; Syncope; Seizure; Epilepsy; Vasovagal; Child

THE CLINICAL COURSE OF PRESYNCOPE IN THE DIFFERENTIAL DIAGNOSIS OF SYNCOPE

Aim. To evaluate the clinical signs and symptoms in the differential diagnosis of syncope. Material and methods. We investigated 160 patients (64 men and 96 women), aged 18-77 years with reflex or cardiac syncope over the last 3 years. The following were investigated: age, sex, age at first syncope, number of presyncopal episodes, number of syncopal episodes, number of sudden syncope without prodromal signs and the circumstances of syncope. Moreover, we assessed the frequencies of prodromal signs in the differential diagnosis of syncope. Results. Patients with reflex syncope were younger compared to patients with cardiac syncope (41,3±16,5 vs. 61,8±12,8; P<0,001) and had lower weight and body mass index (BMI). Reflex syncope patients more often presented with presyncope (10 (2, 20) vs. 2 (1, 3); p=0,01)) and syncope (8,1±7,8 vs. 5,4±1,6; P<0,001). Dyspnea, heart palpitations, feeling of cold or heat, visual disturbances and tinnitus were associated with reflex syncope (P<0,01). Conclusion. The course of syncope may facilitate a diagnostic process of reflex and cardiac syncope.

Diagnostic value of electrocardiographic (resting and 24-h Holter) monitoring in comparison with NT-proBNP in the differential diagnosis of patients with cardiogenic and neurogenic syncope

BackgroundSyncope is a cause of 1–6% of hospitalizations. Both European and American syncope guidelines recommend a 12-lead ECG as part of the evaluation of all patients with unexplained loss of consciousness. ObjectivesThe aim of this study was the assessment of the significance of ECG, Holter ECG and the concentration of NT-proBNP that would be useful in the differentiation of patients with cardiac and reflex syncope. MethodsWe investigated 100 patients (56 men), aged 18–77 years with reflex or cardiac syncope over the last 3 years. The following factors were investigated: age, sex, systolic and diastolic blood pressure, the presence of cardiovascular disease. Moreover, we assessed basic resting ECG parameters and 24-h Holter ECG parameters, and NT-proBNP concentration in the differential diagnosis of syncope. ResultsPatients with reflex syncope were younger compared to patients with cardiac syncope (44.4±16.5 vs. 60.8±12.6; p<0.001). A pathologic resting 12-lead ECG was present more frequently in the group with a cardiogenic type of syncope – 12 (24%) vs. 8 (16%). 24-h Holter ECG monitoring showed no statistically significant difference between minimal, mean and maximal heart rates in the analyzed groups. However, statistically significant differences were observed in the occurrence of ventricular and supraventricular arrhythmias between the investigated groups. Patients with cardiac syncope had significantly higher concentrations of NT-proBNP compared to patients with reflex syncope (448.7±212.2 vs. 68.2±64.1; p<0.0001). ConclusionsElevated NT-proBNP concentration is present in patients with a cardiogenic mechanism of syncope, despite the fact that a resting ECG is inconclusive.

Desmayos y síncopes

Syncope is a transient episode of loss of consciousness, sudden onset, short duration and spontaneous complete recovery, which is produced by a brief reduction in cerebral blood flow. The most common cause of syncope is the vasovagal syncope, which affects young patients and has a good prognosis. Cardiogenic syncope increases with age and depending on the disease responsible may be associated with an increased risk of sudden death. Orthostatic hypotension is also a cause of syncope, mostly affects elderly patients and may be secondary to the use of certain drugs or diseases that produce autonomic failure and diabetes. The diagnosis of syncope is based on clinical history, physical examination, and an electrocardiogram in all patients is recommended. In the differential diagnosis of syncope should be considered epilepsy, certain vascular disorders and the possibility of a psychogenic origin. Treatment of patients with syncope depends on the underlying cause.

Approach to Patients with Syncope in Emergeny Department - An Evidence-Based Review

Syncope is an important health problem, constituting 1%-5% of all emergency service admissions and up to 6% of all hospitalizations. Substantial experience with patient history and physical examination and time are required to diagnose syncope in patients presenting with transient loss of consciousness. In addition, only up to 50% of patients with syncope can be diagnosed with a final diagnosis, despite all efforts. Thus, management of syncope in emergency departments has shifted from reaching a final diagnosis and treatment to short-, moderate-, or long-term risk stratification systems, allowing decisions for outpatient management, including specialized branch care, or admission for further work-up. This review discusses the definition of syncope-related transient loss of consciousness, differential diagnosis of syncope, diagnostic methods and algorithms, and the main risk stratification studies. It also incorporates the recommendations of the American College of Emergency Physicians (ACEP) 2007 policy statement regarding patients with syncope. (JAEM 2014; 13: 82-91)

Natriuretic peptides in the evaluation of syncope in children and adolescents

Introduction. Natriuretic peptides have an increasing role in assessing cardiovascular conditions. The number of papers addressing their role in the evaluation of children with syncope of unclear etiology is sparse. The aim of this study was to determine whether measuring atrial natriuretic peptide (ANP) and the inactive form, N-terminal prohormone of brain natriuretic peptide (NT-proBNP) concentration in children admitted due to differential diagnosis of syncope can be helpful in establishing the most probable cause of this condition. Methods. The study included 88 patients between 9 and 18 years of age hospitalized due to syncope. The control group comprised 25 healthy children. In order to identify the cause of syncope, children with this condition were subjected to cardiologic and neurologic evaluation, and ANP and NT-proBNP concentrations were determined. Results. The syncope group and the controls did not differ significantly in terms of natriuretic peptides concentrations. Similarly, no significant intergroup differences in natriuretic peptide concentrations were documented between children representing various types of response to the tilt test, and between the subgroups of patients with syncope of various origins. Conclusion. Analysis of natriuretic peptides concentrations in children with syncope does not result in unambiguous findings that would enable establishing accurate diagnosis.

P65 – 1653 Neurodiagnostic evaluations for differential diagnosis of syncope or epilepsy

P65 – 1653 Neurodiagnostic evaluations for differential diagnosis of syncope or epilepsy

Clinical Approach to Syncope in Children

Pediatric syncope is one of the most common neurological problems in the pediatric population in both the office setting and in the emergency department. The abrupt brief loss of consciousness is usually dramatic and alarming to patients, family, onlookers, and providers. The differential diagnosis of syncope is wide but most cases are benign. A comprehensive but focused history and a thorough clinical examination are usually the cornerstones in the diagnosis of high-risk patients. It should be noted that the evaluation of syncope in children is costly and testing provides a low diagnostic yield. This chapter reviews the various types of syncope and provides a succinct clinical approach to the diagnosis, investigation, and management of syncope in children.