Neurocardiogenic syncope natural history

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

Vasovagal syncope usually has an easily identified triggering event such as emotional stress, trauma, pain, the sight of blood, or prolonged standing. Syncope recurs in few patients, while others just experience a single episode. The prognosis is usually good, although prolonged hypotension may cause severe damage. Mortality associated with syncope is largely due to severity of the underlying disease rather than syncope per se.

Natural History

The natural history of neurocardiogenic syncope is extremely variable; some patients experience single episode while others have recurrent episodes. [1]

In an european study, 465 patients were evaluated for an early (1 month) and late (2 years) death rate and syncopal relapses of patients referred for syncope to 11 general hospitals emergency departments. The following results were found:[2]

  • The death rate was higher (17% of all deaths) in the first month of observation
  • Reoccurrence of the syncopal episode was low overall in both the short and the long term (0.3% and 0.8% in the first month and in the second year, respectively).
  • Mortality was higher in patients having previous cardiovascular disease or in those displaying ECG abnormalities. Both of these two factors represent the main predictors of short or long-term mortality on multivariate analysis

Prognosis

Vasovagal syncope appears to have a benign prognosis.[3] Patients recover completely within minutes to hours and have excellent prognosis as far as survival is concerned.[4] If syncope is symptomatic of an underlying condition, then the prognosis will reflect the course of the disorder and not the syncope itself.[5][6] Such patient's should be stratified with respect to the risk of a cardiovascular event and/or sudden cardiac death and further evaluation should be made. [7]

Supportive Trial Data

  • A study of 334 patients with a mean follow up of 30.4 ± 21 months, showed good survival of patients with neurocardiogenic syncope, presenting after an abnormal head-up tilt (HUT) test. [8] The study showed that there were no cardiac deaths in during 30.4 ± 21 months. However, 101 patients (30.2%) had recurrences (1 recurrence, n = 64; > or =2, n = 37), which were not influenced by the type of response during HUT or by age.

Prognostic indicators

  • The duration of loss of consciousness during the syncope.[9]
  • Co-morbid disease or Underlying cardiac illness (Hemodynaically important aortic stenosis) [10]
  • Increased age.

Predictors for recurrences of vasovagal syncope

The presence of following conditions increase the risk of vasovagal syncope: [11]

  • The number of previous syncope and presyncope.
  • Female gender.
  • History of bronchial asthma.

A group of authors have designed a simple clinical risk score to predict the risk of recurrence of vasovagal syncope.[11]

Complication

The main danger of fainting fits or vasovagal syncope is the risk of injury by falling while unconscious. American Heart Association (AHA), North American Society of Pacing and Electrophysiology (NASPE, now Heart Rhythm Society, HRS) and European Society of Cardiology have published recommendations for driving in patients with syncope.[12][13][14]

The quality of life (QoL) of patients suffering from neurocardiogenic shock is similar to those with NYHA class II-III heart failure.[15]

Risk of death and life-threatening events

Major risk factors for sudden cardiac death and overall mortality in patients are structural heart diseases[16][17] and primary electrical disturbances.[18]

Recurrence of syncope and risk of physical injury

  • Morbidity is particulary high in the elderly due to the following contributing factors:[19][20]
    • Loss of confidence.
    • Depressive illness.
    • Fear of falling, to fractures and subsequent institutionalization.
  • Mortality in syncope patients depends on the underlying cause:[21]
    • Cardiac causes (arrhythmias or cardiovascular disease) have a 20-30% mortality.
    • Non-cardiac causes have 5-10% mortality.

However, a major drawback in determining the true mortality rate is that most individuals with transient loss of consciousness do not seek medical advice.

Related Chapters

Reference

  1. ↑ Alboni P, Brignole M, Degli Uberti EC (2007). "Is vasovagal syncope a disease?". Europace. 9 (2): 83–7. doi:10.1093/europace/eul179. PMID 17272328.
  2. ↑ Ungar A, Del Rosso A, Giada F, Bartoletti A, Furlan R, Quartieri F; et al. (2010). "Early and late outcome of treated patients referred for syncope to emergency department: the EGSYS 2 follow-up study". Eur Heart J. 31 (16): 2021–6. doi:10.1093/eurheartj/ehq017. PMID 20167743.
  3. ↑ Soteriades ES, Evans JC, Larson MG, Chen MH, Chen L, Benjamin EJ; et al. (2002). "Incidence and prognosis of syncope". N Engl J Med. 347 (12): 878–85. doi:10.1056/NEJMoa012407. PMID 12239256.
  4. ↑ Ruiz GA, Peralta A, Gonzalez-Zuelgaray J, Duce E (1995). "Evolution of patients with clinical neurocardiogenic (vasovagal) syncope not subjected to specific treatment". Am Heart J. 130 (2): 345–50. PMID 7631619.
  5. ↑ Eagle KA, Black HR, Cook EF, Goldman L (1985). "Evaluation of prognostic classifications for patients with syncope". Am. J. Med. 79 (4): 455–60. PMID 4050832. Retrieved 2012-05-17. Unknown parameter |month= ignored (help)
  6. ↑ Morady F, Shen E, Schwartz A, Hess D, Bhandari A, Sung RJ, Scheinman MM (1983). "Long-term follow-up of patients with recurrent unexplained syncope evaluated by electrophysiologic testing". J. Am. Coll. Cardiol. 2 (6): 1053–9. PMID 6630777. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  7. ↑ Veltmann C, Borggrefe M, Wolpert C, Schimpf R (2010). "Evaluation and management of syncope". Minerva Cardioangiol. 58 (6): 701–15. PMID 21135810.
  8. ↑ Barón-Esquivias G, Errázquin F, Pedrote A, Cayuela A, Gómez S, Aguilera A, Campos A, Fernández M, Valle JI, Redondo M, Fernández JM, Martínez A, Burgos J, Martínez-Rubio A (2004). "Long-term outcome of patients with vasovagal syncope". Am. Heart J. 147 (5): 883–9. doi:10.1016/j.ahj.2003.11.022. PMID 15131546. Retrieved 2012-05-17. Unknown parameter |month= ignored (help)
  9. ↑ Zyśko D, Gajek J, Kozluk E, Agrawal AK, Smereka J, Checiński I (2010). "The clinical relevance of the duration of loss of consciousness provoked by tilt testing". Acta Cardiol. 65 (2): 203–9. PMID 20458828. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  10. ↑ Kapoor WN, Karpf M, Wieand S, Peterson JR, Levey GS (1983). "A prospective evaluation and follow-up of patients with syncope". N. Engl. J. Med. 309 (4): 197–204. doi:10.1056/NEJM198307283090401. PMID 6866032. Retrieved 2012-05-17. Unknown parameter |month= ignored (help)
  11. ↑ 11.0 11.1 Aydin MA, Maas R, Mortensen K, Steinig T, Klemm H, Risius T, Meinertz T, Willems S, Morillo CA, Ventura R (2009). "Predicting recurrence of vasovagal syncope: a simple risk score for the clinical routine". J. Cardiovasc. Electrophysiol. 20 (4): 416–21. doi:10.1111/j.1540-8167.2008.01352.x. PMID 19017338. Retrieved 2012-05-17. Unknown parameter |month= ignored (help)
  12. ↑ Epstein AE, Miles WM, Benditt DG, Camm AJ, Darling EJ, Friedman PL, Garson A, Harvey JC, Kidwell GA, Klein GJ, Levine PA, Marchlinski FE, Prystowsky EN, Wilkoff BL (1996). "Personal and public safety issues related to arrhythmias that may affect consciousness: implications for regulation and physician recommendations. A medical/scientific statement from the American Heart Association and the North American Society of Pacing and Electrophysiology". Circulation. 94 (5): 1147–66. PMID 8790068. Retrieved 2012-05-17. Unknown parameter |month= ignored (help)
  13. ↑ Epstein AE, Baessler CA, Curtis AB, Estes NA, Gersh BJ, Grubb B, Mitchell LB (2007). "Addendum to "Personal and public safety issues related to arrhythmias that may affect consciousness: implications for regulation and physician recommendations: a medical/scientific statement from the American Heart Association and the North American Society of Pacing and Electrophysiology": public safety issues in patients with implantable defibrillators: a scientific statement from the American Heart Association and the Heart Rhythm Society". Circulation. 115 (9): 1170–6. doi:10.1161/CIRCULATIONAHA.106.180203. PMID 17287391. Retrieved 2012-05-17. Unknown parameter |month= ignored (help)
  14. ↑ Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB, Deharo JC, Gajek J, Gjesdal K, Krahn A, Massin M, Pepi M, Pezawas T, Ruiz Granell R, Sarasin F, Ungar A, van Dijk JG, Walma EP, Wieling W (2009). "Guidelines for the diagnosis and management of syncope (version 2009)". Eur. Heart J. 30 (21): 2631–71. doi:10.1093/eurheartj/ehp298. PMC 3295536. PMID 19713422. Retrieved 2012-05-17. Unknown parameter |month= ignored (help)
  15. ↑ Barón-Esquivias G, Cayuela A, Gómez S, Aguilera A, Campos A, Fernández M, Cabezón S, Morán JE, Valle JI, Martínez A, Pedrote A, Errázquin F, Burgos J (2003). "[Quality of life in patients with vasovagal syncope. Clinical parameters influence]". Med Clin (Barc) (in Spanish; Castilian). 121 (7): 245–9. PMID 12975035. Retrieved 2012-05-17. Unknown parameter |month= ignored (help)
  16. ↑ Martin TP, Hanusa BH, Kapoor WN (1997). "Risk stratification of patients with syncope". Ann Emerg Med. 29 (4): 459–66. PMID 9095005. Retrieved 2012-05-17. Unknown parameter |month= ignored (help)
  17. ↑ Olshansky B, Poole JE, Johnson G, Anderson J, Hellkamp AS, Packer D, Mark DB, Lee KL, Bardy GH (2008). "Syncope predicts the outcome of cardiomyopathy patients: analysis of the SCD-HeFT study". J. Am. Coll. Cardiol. 51 (13): 1277–82. doi:10.1016/j.jacc.2007.11.065. PMID 18371559. Retrieved 2012-05-17. Unknown parameter |month= ignored (help)
  18. ↑ Wehrens XH, Vos MA, Doevendans PA, Wellens HJ (2002). "Novel insights in the congenital long QT syndrome". Ann. Intern. Med. 137 (12): 981–92. PMID 12484714. Retrieved 2012-05-17. Unknown parameter |month= ignored (help)
  19. ↑ Ungar A, Mussi C, Del Rosso A, Noro G, Abete P, Ghirelli L, Cellai T, Landi A, Salvioli G, Rengo F, Marchionni N, Masotti G (2006). "Diagnosis and characteristics of syncope in older patients referred to geriatric departments". J Am Geriatr Soc. 54 (10): 1531–6. doi:10.1111/j.1532-5415.2006.00891.x. PMID 17038070. Retrieved 2012-05-17. Unknown parameter |month= ignored (help)
  20. ↑ Costantino G, Perego F, Dipaola F, Borella M, Galli A, Cantoni G, Dell'Orto S, Dassi S, Filardo N, Duca PG, Montano N, Furlan R (2008). "Short- and long-term prognosis of syncope, risk factors, and role of hospital admission: results from the STePS (Short-Term Prognosis of Syncope) study". J. Am. Coll. Cardiol. 51 (3): 276–83. doi:10.1016/j.jacc.2007.08.059. PMID 18206736. Retrieved 2012-05-17. Unknown parameter |month= ignored (help)
  21. ↑ White CM, Tsikouris JP (2000). "A review of pathophysiology and therapy of patients with vasovagal syncope". Pharmacotherapy. 20 (2): 158–65. PMID 10678294.


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