Syncope classification: Difference between revisions

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Latest revision as of 14:02, 15 December 2021

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]: Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2] Sara Zand, M.D.[3]

Overview

Syncope is defined as abrupt, transient complete loss of consciousness, inability to keep postural tone, rapid spontaneous recovery with the mechanism of cerebral hypoperfusion. Syncope is usually classified based on the underlying mechanisms leading to hypoperfusion. Syncope is classified to reflex-mediated, orthostatic hypotension, and cardiovascular subtypes. Neurally-mediated syncope (common faint) is the most common type of reflex syncope in younger patients occurs during upright position (standing, sitting) with prodrome symptoms including diaphoresis, warmth, nausea, and pallor, usually after emotional stress, pain, medical setting. Orthostasis hypotension is explained as reduction in systolic blood pressure of ≥20 mmHg or diastolic blood pressure of ≥10 mm Hg within 3 minutes of standing position and is common in older patients. Carotid sinus syndrome which is a type of reflex syncope due to carotid sinus hypersensitivity is defined as pause ≥3 seconds and/or a reduction of systolic blood pressure ≥50 mm Hg during stimulation of the carotid sinus and is more common in older patients. There are some conditions that are incorrectly diagnosed as syncope. These conditions are usually associated with partial or complete loss of consciousness such as epilepsy, metabolic disorders, transient ischemic attack or conditions with loss of posture and without loss of consciousness like cataplexy, drop attacks, falls and pseudo-syncope.

Classification

Syncope is usually classified based on the underlying mechanisms leading to cerebral hypoperfusion. According to 2017AHA/ACC/HRS guideline, syncope is classified to:^[1]

Terms	Definition
Syncope	Abrupt, transient complete loss of consciousness, inability to keep postural tone, rapid spontaneous recovery with the mechanism of cerebral hypoperfusion
Pre syncope, near syncope	The symptoms before syncope including lightheadedness, visual sensations, such as tunnel vision or graying out, variable degrees of altered consciousness without complete loss of consciousness
Unexplained syncope	Undetermined etiology after initial evaluation including history, physical examination, ECG
Orthostatic intolerance	Frequent, recurrent, or persistent lightheadedness, palpitations, tremulous, generalized weakness, blurred vision, exercise intolerance, fatigue upon standing. These symptoms happen with or without orthostasis tachycardia, orthostasis intolerance or syncope. Patients have more than one symptoms with inability to maintain standing posture.
Orthostatic tachycardia	Increasing heart rate ≥30 bpm within 10 minutes after standing (without exercise) from recumbent position oror ≥40 bpm in individuals 12–19 year of age
Orthostatic hypotension	Decreasing systolic blood pressure of ≥20 mmHg or diastolic blood pressure of ≥10 mm Hg in standing position
Initial (immediate) orthostatic hypotension	A transient reduction in blood pressure within 15 seconds after standing accompanied by syncope or presyncope
Classic orthostatic hypotension	A sustain reduction in systolic blood pressure of ≥20 mmHg or diastolic blood pressure of ≥10 mm Hg within 3 minutes of standing position
Delayed orthostatic hypotension	A sustain reduction in systolic blood pressure of ≥20 mmHg (or 30 mm Hg in patients with supine hypertension) or diastolic blood pressure of ≥10 mm Hg after 3 minutes of standing position
Neurogenic hypotension	A subtype of orthostasis hypotension due to central or peripheral autonomic nervous system dysfunction
Cardiac syncope	tachyarrhythmia, bradyarhythmia, hypotension due to Low cardiac output state, valvular , bloodflow obstruction, vascular dissection, vasodilation leading syncope
Non cardiac syncope	reflex syncope, orthostatic hypotension, volume depletion, dehydration, blood loss
Reflex (neurally mediated) syncope	Syncope due to vasodilation, bradycardia or both
Vasovagal syncope	The most common type of reflex syncope mediated by vasovagal reflex during upright position( standing , sitting) presented with prodrome symptoms including diaphoresis, warmth, nausea, and pallor after emotional stress, pain, medical setting. Taking history and [[physical examination] and eyewitness may helpful for the diagnosis.
Carotid sinus syndrome	A type of reflex syncope due to carotid sinus hypersensitivity defined as pause ≥3 seconds and/or a reduction of systolic blood pressure ≥50 mm Hg during stimulation of the carotid sinus, more common in older patients
Situational syncope	A type of reflex syncope after specific physical functions such as coughing, laughing, swallowing, micturition, defecation
Postural orthostatic tachycardia syndrome (POTS)	an increase in heart rate of ≥30 bpm during a positional change from supine to standing (or ≥40 bpm in those 12–19 year of age) in the absence of orthostatic hypotension (>20 mm Hg reduction in systolic blood pressure). [[Heart rate> 120/ min in standing position and symptoms such as lightheadedness, palpitations, tremulousness, generalized weakness, blurred vision, exercise intolerance, and fatigue in standing position which are not related to specific functions ( bloating, nausea, diarrhea, abdominal pain.
Psychogenic pseudosyncope	False unconsciousness in the absent of cardiac, reflex, neurologic, metabolic causes

There are some conditions that are incorrectly diagnosed as syncope. These conditions are usually associated with partial or complete loss of consciousness or with loss of posture and without loss of consciousness. The table below is one of the suggested classification systems for syncope:^[2]^[3]^[4]


Syncope due to Orthostatic Hypotension
Neurally-Mediated Syncope
Vasovagal
Triggered by emotional distress
Triggered by orthostatic distress
Situational
Cough, sneeze
Gastrointestinal stimulation: Swallow Defecation Visceral pain
Micturition
Others: Weight lifting laughter Brass instrument playing
Carotid sinus syncope
Autonomic failure
Primary: Pure autonomic failure Multiple system atrophy Parkinson’s disease with autonomic failure Lewy body dementia
Secondary: Diabetes Amyloidosis Spinal cord injuries
Drug induced:
Alcohol Vasodilators Diuretics Beta-adrenergic blockers
Volume depletion
Inadequate fluid intake (hot weather) Diarrhea Vomiting
Cardiovascular Syncope
Arrhythmia
Bradyarrhythmia: Sinus node dysfunction Atrioventricular conduction system disease Implanted device malfunction
Tachyarrhythmia: Supraventricular including atrial fibrillation Ventricular (idiopathic secondary to structural heart disease, or due to channelopathies)
Structural heart disease
Cardiac: Cardiac valvular disease Acute myocardial infarction/ischemia Hypertrophic cardiomyopathy Cardiac masses (atrial myxoma, tumors, etc.)
Pericardial disease: Tamponade Congenital anomalies of coronary arteries Prosthetic valves dysfunction
Other cardiovascular:
Pulmonary embolus Pulmonary hypertension Acute aortic dissection
Conditions Incorrectly Diagnosed as Syncope
Disorders with partial or complete loss of consciousness
Epilepsy
Metabolic disorders: Hypoglycemia Hypoxia Hyperventilation with hypocapnia
Intoxication
Vertebrobasilar TIA
Conditions without loss of consciousness
Cataplexy
Falls
Functional (pseudoscope)
Drop attacks
TIA of carotid origin

The above table adopted from ESC guideline

References

↑ Shen, Win-Kuang; Sheldon, Robert S.; Benditt, David G.; Cohen, Mitchell I.; Forman, Daniel E.; Goldberger, Zachary D.; Grubb, Blair P.; Hamdan, Mohamed H.; Krahn, Andrew D.; Link, Mark S.; Olshansky, Brian; Raj, Satish R.; Sandhu, Roopinder Kaur; Sorajja, Dan; Sun, Benjamin C.; Yancy, Clyde W. (2017). "2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society". Circulation. 136 (5). doi:10.1161/CIR.0000000000000499. ISSN 0009-7322.
↑ Moya, A.; Sutton, R.; Ammirati, F.; Blanc, J.-J.; Brignole, M.; Dahm, J. B.; Deharo, J.-C.; Gajek, J.; Gjesdal, K.; Krahn, A.; Massin, M.; Pepi, M.; Pezawas, T.; Granell, R. R.; Sarasin, F.; Ungar, A.; van Dijk, J. G.; Walma, E. P.; Wieling, W.; Abe, H.; Benditt, D. G.; Decker, W. W.; Grubb, B. P.; Kaufmann, H.; Morillo, C.; Olshansky, B.; Parry, S. W.; Sheldon, R.; Shen, W. K.; Vahanian, A.; Auricchio, A.; Bax, J.; Ceconi, C.; Dean, V.; Filippatos, G.; Funck-Brentano, C.; Hobbs, R.; Kearney, P.; McDonagh, T.; McGregor, K.; Popescu, B. A.; Reiner, Z.; Sechtem, U.; Sirnes, P. A.; Tendera, M.; Vardas, P.; Widimsky, P.; Auricchio, A.; Acarturk, E.; Andreotti, F.; Asteggiano, R.; Bauersfeld, U.; Bellou, A.; Benetos, A.; Brandt, J.; Chung, M. K.; Cortelli, P.; Da Costa, A.; Extramiana, F.; Ferro, J.; Gorenek, B.; Hedman, A.; Hirsch, R.; Kaliska, G.; Kenny, R. A.; Kjeldsen, K. P.; Lampert, R.; Molgard, H.; Paju, R.; Puodziukynas, A.; Raviele, A.; Roman, P.; Scherer, M.; Schondorf, R.; Sicari, R.; Vanbrabant, P.; Wolpert, C.; Zamorano, J. L. (2009). "Guidelines for the diagnosis and management of syncope (version 2009): The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC)". European Heart Journal. 30 (21): 2631–2671. doi:10.1093/eurheartj/ehp298. ISSN 0195-668X.
↑ Sutton, Richard (2013). "Clinical Classification of Syncope". Progress in Cardiovascular Diseases. 55 (4): 339–344. doi:10.1016/j.pcad.2012.11.005. ISSN 0033-0620.
↑ Puppala, Venkata Krishna; Dickinson, Oana; Benditt, David G. (2014). "Syncope: Classification and risk stratification". Journal of Cardiology. 63 (3): 171–177. doi:10.1016/j.jjcc.2013.03.019. ISSN 0914-5087.

[ShenSheldon2017-1] Shen, Win-Kuang; Sheldon, Robert S.; Benditt, David G.; Cohen, Mitchell I.; Forman, Daniel E.; Goldberger, Zachary D.; Grubb, Blair P.; Hamdan, Mohamed H.; Krahn, Andrew D.; Link, Mark S.; Olshansky, Brian; Raj, Satish R.; Sandhu, Roopinder Kaur; Sorajja, Dan; Sun, Benjamin C.; Yancy, Clyde W. (2017). "2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society". Circulation. 136 (5). doi:10.1161/CIR.0000000000000499. ISSN 0009-7322.

[MoyaSutton2009-2] Moya, A.; Sutton, R.; Ammirati, F.; Blanc, J.-J.; Brignole, M.; Dahm, J. B.; Deharo, J.-C.; Gajek, J.; Gjesdal, K.; Krahn, A.; Massin, M.; Pepi, M.; Pezawas, T.; Granell, R. R.; Sarasin, F.; Ungar, A.; van Dijk, J. G.; Walma, E. P.; Wieling, W.; Abe, H.; Benditt, D. G.; Decker, W. W.; Grubb, B. P.; Kaufmann, H.; Morillo, C.; Olshansky, B.; Parry, S. W.; Sheldon, R.; Shen, W. K.; Vahanian, A.; Auricchio, A.; Bax, J.; Ceconi, C.; Dean, V.; Filippatos, G.; Funck-Brentano, C.; Hobbs, R.; Kearney, P.; McDonagh, T.; McGregor, K.; Popescu, B. A.; Reiner, Z.; Sechtem, U.; Sirnes, P. A.; Tendera, M.; Vardas, P.; Widimsky, P.; Auricchio, A.; Acarturk, E.; Andreotti, F.; Asteggiano, R.; Bauersfeld, U.; Bellou, A.; Benetos, A.; Brandt, J.; Chung, M. K.; Cortelli, P.; Da Costa, A.; Extramiana, F.; Ferro, J.; Gorenek, B.; Hedman, A.; Hirsch, R.; Kaliska, G.; Kenny, R. A.; Kjeldsen, K. P.; Lampert, R.; Molgard, H.; Paju, R.; Puodziukynas, A.; Raviele, A.; Roman, P.; Scherer, M.; Schondorf, R.; Sicari, R.; Vanbrabant, P.; Wolpert, C.; Zamorano, J. L. (2009). "Guidelines for the diagnosis and management of syncope (version 2009): The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC)". European Heart Journal. 30 (21): 2631–2671. doi:10.1093/eurheartj/ehp298. ISSN 0195-668X.

[Sutton2013-3] Sutton, Richard (2013). "Clinical Classification of Syncope". Progress in Cardiovascular Diseases. 55 (4): 339–344. doi:10.1016/j.pcad.2012.11.005. ISSN 0033-0620.

[PuppalaDickinson2014-4] Puppala, Venkata Krishna; Dickinson, Oana; Benditt, David G. (2014). "Syncope: Classification and risk stratification". Journal of Cardiology. 63 (3): 171–177. doi:10.1016/j.jjcc.2013.03.019. ISSN 0914-5087.

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@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Syncope}}
-{{CMG}}: {{AE}} {{Sahar}}
+{{CMG}}: {{AE}} {{Sahar}} {{Sara.Zand}}
 ==Overview==
-Vasovagal (situational) syncope, one of the most common types, may occur in scary or embarrassing situations or during blood drawing, coughing, or urinating. Other types include postural syncope (caused by a changing in body posture), cardiac syncope (due to heart-related conditions), and neurological syncope (due to neurological conditions). There are many other causes of syncope including low blood sugar levels and lung disease such as [[emphysema]] and a [[pulmonary embolus]]. The cause of the fainting can be determined by a doctor using a complete history, physical, and various diagnostic tests.
+[[Syncope]] is defined as abrupt, transient complete loss of consciousness, inability to keep postural tone, rapid spontaneous recovery with the mechanism of [[cerebral hypoperfusion]]. [[Syncope]] is usually [[Classification|classified]] based on the underlying mechanisms leading to [[hypoperfusion]]. [[Syncope]] is [[Classification|classified]] to [[reflex-mediated]], [[orthostatic hypotension]], and [[cardiovascular]] subtypes. Neurally-mediated syncope (common faint) is the most common type of [[reflex syncope]]  in younger [[patients]] occurs during upright position (standing, sitting)  with prodrome [[symptoms]] including [[diaphoresis]], [[warmth]], [[nausea]], and [[pallor]], usually  after [[emotional stress]], [[pain]], medical setting. [[Orthostasis hypotension]] is explained as reduction in [[systolic blood pressure]] of  ≥20 mmHg or [[diastolic blood pressure]] of ≥10 mm Hg within 3 minutes of standing position and is common in older [[patients]]. [[Carotid sinus syndrome]] which is a type of   reflex [[syncope]] due to [[carotid sinus]] hypersensitivity  is defined as  [[pause]] ≥3 seconds and/or a reduction of [[systolic blood  pressure]] ≥50 mm Hg during  stimulation of the [[carotid sinus]] and  is more common in older [[patients]]. There are some [[conditions]] that are incorrectly [[Diagnose|diagnosed]] as [[syncope]]. These [[conditions]] are usually associated with partial or complete [[loss of consciousness]] such as [[epilepsy]], [[metabolic disorders]], [[transient ischemic attack]] or [[conditions]] with loss of posture and without loss of consciousness like [[cataplexy]], drop attacks, [[falls]] and pseudo-syncope.
-Syncope definition, according to European Task Force, can be catalogued as T-LOC (transient loss of consciousness) due to cerebral hypo perfusion, with a rapid onset, brief in duration, and complete spontaneous recovery. <ref name="pmid19713422">{{cite journal| author=Task Force for the Diagnosis and Management of Syncope. European Society of Cardiology (ESC). European Heart Rhythm Association (EHRA). Heart Failure Association (HFA). Heart Rhythm Society (HRS). Moya A et al.| title=Guidelines for the diagnosis and management of syncope (version 2009). | journal=Eur Heart J | year= 2009 | volume= 30 | issue= 21 | pages= 2631-71 | pmid=19713422 | doi=10.1093/eurheartj/ehp298 | pmc=PMC3295536 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19713422  }} </ref>  Sometimes there can be prodromal period, in which the patient experiences lightheadedness, sweating, and nausea. Pre- syncope refers to the prodromal period without leading to T- LOC. <ref name="pmid19713422">{{cite journal| author=Task Force for the Diagnosis and Management of Syncope. European Society of Cardiology (ESC). European Heart Rhythm Association (EHRA). Heart Failure Association (HFA). Heart Rhythm Society (HRS). Moya A et al.| title=Guidelines for the diagnosis and management of syncope (version 2009). | journal=Eur Heart J | year= 2009 | volume= 30 | issue= 21 | pages= 2631-71 | pmid=19713422 | doi=10.1093/eurheartj/ehp298 | pmc=PMC3295536 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19713422  }} </ref>
 ==Classification==
-Syncope is usually [[Classification|classified]] based on the underlying [[mechanisms]] leading to [[hypoperfusion]]. The table below is one of the suggested [[classification]] systems for syncope:<ref name="MoyaSutton2009">{{cite journal|last1=Moya|first1=A.|last2=Sutton|first2=R.|last3=Ammirati|first3=F.|last4=Blanc|first4=J.-J.|last5=Brignole|first5=M.|last6=Dahm|first6=J. B.|last7=Deharo|first7=J.-C.|last8=Gajek|first8=J.|last9=Gjesdal|first9=K.|last10=Krahn|first10=A.|last11=Massin|first11=M.|last12=Pepi|first12=M.|last13=Pezawas|first13=T.|last14=Granell|first14=R. R.|last15=Sarasin|first15=F.|last16=Ungar|first16=A.|last17=van Dijk|first17=J. G.|last18=Walma|first18=E. P.|last19=Wieling|first19=W.|last20=Abe|first20=H.|last21=Benditt|first21=D. G.|last22=Decker|first22=W. W.|last23=Grubb|first23=B. P.|last24=Kaufmann|first24=H.|last25=Morillo|first25=C.|last26=Olshansky|first26=B.|last27=Parry|first27=S. W.|last28=Sheldon|first28=R.|last29=Shen|first29=W. K.|last30=Vahanian|first30=A.|last31=Auricchio|first31=A.|last32=Bax|first32=J.|last33=Ceconi|first33=C.|last34=Dean|first34=V.|last35=Filippatos|first35=G.|last36=Funck-Brentano|first36=C.|last37=Hobbs|first37=R.|last38=Kearney|first38=P.|last39=McDonagh|first39=T.|last40=McGregor|first40=K.|last41=Popescu|first41=B. A.|last42=Reiner|first42=Z.|last43=Sechtem|first43=U.|last44=Sirnes|first44=P. A.|last45=Tendera|first45=M.|last46=Vardas|first46=P.|last47=Widimsky|first47=P.|last48=Auricchio|first48=A.|last49=Acarturk|first49=E.|last50=Andreotti|first50=F.|last51=Asteggiano|first51=R.|last52=Bauersfeld|first52=U.|last53=Bellou|first53=A.|last54=Benetos|first54=A.|last55=Brandt|first55=J.|last56=Chung|first56=M. K.|last57=Cortelli|first57=P.|last58=Da Costa|first58=A.|last59=Extramiana|first59=F.|last60=Ferro|first60=J.|last61=Gorenek|first61=B.|last62=Hedman|first62=A.|last63=Hirsch|first63=R.|last64=Kaliska|first64=G.|last65=Kenny|first65=R. A.|last66=Kjeldsen|first66=K. P.|last67=Lampert|first67=R.|last68=Molgard|first68=H.|last69=Paju|first69=R.|last70=Puodziukynas|first70=A.|last71=Raviele|first71=A.|last72=Roman|first72=P.|last73=Scherer|first73=M.|last74=Schondorf|first74=R.|last75=Sicari|first75=R.|last76=Vanbrabant|first76=P.|last77=Wolpert|first77=C.|last78=Zamorano|first78=J. L.|title=Guidelines for the diagnosis and management of syncope (version 2009): The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC)|journal=European Heart Journal|volume=30|issue=21|year=2009|pages=2631–2671|issn=0195-668X|doi=10.1093/eurheartj/ehp298}}</ref>
+[[Syncope]] is usually [[Classification|classified]] based on the underlying mechanisms leading to [[cerebral]] [[hypoperfusion]]. According to '''2017AHA/ACC/HRS''' guideline, [[syncope]] is [[Classification|classified]] to:<ref name="ShenSheldon2017">{{cite journal|last1=Shen|first1=Win-Kuang|last2=Sheldon|first2=Robert S.|last3=Benditt|first3=David G.|last4=Cohen|first4=Mitchell I.|last5=Forman|first5=Daniel E.|last6=Goldberger|first6=Zachary D.|last7=Grubb|first7=Blair P.|last8=Hamdan|first8=Mohamed H.|last9=Krahn|first9=Andrew D.|last10=Link|first10=Mark S.|last11=Olshansky|first11=Brian|last12=Raj|first12=Satish R.|last13=Sandhu|first13=Roopinder Kaur|last14=Sorajja|first14=Dan|last15=Sun|first15=Benjamin C.|last16=Yancy|first16=Clyde W.|title=2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society|journal=Circulation|volume=136|issue=5|year=2017|issn=0009-7322|doi=10.1161/CIR.0000000000000499}}</ref>
+{| style="border: 2px solid #4479BA; align="left"
+! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Terms}}
+! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF| Definition}}
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Syncope]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Abrupt, transient complete loss of consciousness, inability to keep postural tone, rapid spontaneous recovery with the mechanism of [[cerebral hypoperfusion]]
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[ Pre syncope]], [[near syncope]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | The symptoms before [[syncope]] including [[lightheadedness]], [[visual sensations]], such as [[tunnel vision]] or [[graying out]], variable degrees of [[altered consciousness]] without complete [[loss of consciousness]]
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[ Unexplained syncope]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Undetermined etiology after initial evaluation including [[history]], [[physical examination]], [[ECG]]
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Orthostatic intolerance]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  Frequent, recurrent, or persistent [[lightheadedness]], [[palpitations]], [[tremulous]], generalized [[weakness]], [[blurred vision]], [[exercise intolerance]], [[fatigue]] upon [[standing]]. These symptoms happen with or without [[orthostasis tachycardia]], [[orthostasis intolerance]] or [[syncope]]. Patients have more than one symptoms with inability to maintain  standing posture.
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Orthostatic tachycardia]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  Increasing [[heart rate]] ≥30 bpm within 10 minutes after standing (without exercise) from recumbent position oror ≥40 bpm in individuals 12–19 year of age
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Orthostatic hypotension]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  Decreasing [[systolic blood pressure]] of  ≥20 mmHg or [[diastolic blood pressure]] of ≥10 mm Hg in standing position
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Initial (immediate) [[orthostatic hypotension]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  A transient reduction in [[blood pressure]] within 15 seconds after standing accompanied by [[syncope]] or [[presyncope]]
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |   Classic [[orthostatic hypotension]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  A sustain reduction in [[systolic blood pressure]] of  ≥20 mmHg or [[diastolic blood pressure]] of ≥10 mm Hg within 3 minutes of standing position
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |   Delayed [[orthostatic hypotension]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  A sustain reduction in [[systolic blood pressure]] of  ≥20 mmHg (or 30 mm Hg in patients with supine [[hypertension]]) or [[diastolic blood pressure]] of ≥10 mm Hg after 3 minutes of standing position
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |   Neurogenic [[hypotension]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  A subtype of [[orthostasis hypotension]] due to central or peripheral autonomic  nervous system dysfunction
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |   Cardiac [[syncope]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |   [[tachyarrhythmia]], [[bradyarhythmia]], [[hypotension]] due to [[Low cardiac output]] state, valvular , [[bloodflow obstruction]], vascular dissection, [[vasodilation]] leading [[syncope]]
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |   Non cardiac [[syncope]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[ reflex syncope]], [[orthostatic hypotension]], volume depletion, [[dehydration]], [[blood loss]]
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  Reflex (neurally mediated) [[syncope]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[ Syncope]] due to [[vasodilation]], [[bradycardia]] or both
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  Vasovagal [[syncope]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | The most common type of [[reflex syncope]] mediated by vasovagal reflex during upright position( standing , sitting) presented with prodrome symptoms including [[diaphoresis]], [[warmth]], [[nausea]], and [[pallor]] after [[emotional stress]], [[pain]], medical setting. Taking [[history]] and [[physical examination] and eyewitness may helpful for the diagnosis.
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  [[Carotid sinus syndrome]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  A type of   reflex [[syncope]] due to carotid sinus hypersensitivity defined as  [[pause]] ≥3 seconds and/or a reduction of [[systolic blood  pressure]] ≥50 mm Hg during  stimulation of the [[carotid sinus]], more common in older patients
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  [[Situational syncope]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | A type of reflex [[syncope]] after specific  physical functions such as [[coughing]], [[laughing]], [[swallowing]], [[micturition]], [[defecation]]
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  [[Postural orthostatic tachycardia syndrome]] (POTS)
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |   an increase in [[heart rate]] of ≥30 bpm during a positional change from supine to standing (or ≥40 bpm in those 12–19 year of age) in the absence of [[orthostatic hypotension]] (>20 mm Hg reduction in [[systolic blood pressure]]). [[Heart rate> 120/ min in standing position and symptoms such as [[lightheadedness]], [[palpitations]], [[tremulousness]], [[generalized weakness]], [[blurred vision]], [[exercise intolerance]], and [[fatigue]] in standing position which are not related to specific functions ( [[bloating]], [[nausea]], [[diarrhea]], [[abdominal pain]].
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  [[Psychogenic pseudosyncope]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |   False  unconsciousness in the absent of [[cardiac]], [[reflex]], [[neurologic]], [[metabolic]] causes
+|}
+There are some [[conditions]] that are incorrectly [[Diagnose|diagnosed]] as syncope. These [[conditions]] are usually associated with partial or complete [[loss of consciousness]] or with loss of posture and without [[loss of consciousness]].
+The table below is one of the suggested [[classification]] systems for syncope:<ref name="MoyaSutton2009">{{cite journal|last1=Moya|first1=A.|last2=Sutton|first2=R.|last3=Ammirati|first3=F.|last4=Blanc|first4=J.-J.|last5=Brignole|first5=M.|last6=Dahm|first6=J. B.|last7=Deharo|first7=J.-C.|last8=Gajek|first8=J.|last9=Gjesdal|first9=K.|last10=Krahn|first10=A.|last11=Massin|first11=M.|last12=Pepi|first12=M.|last13=Pezawas|first13=T.|last14=Granell|first14=R. R.|last15=Sarasin|first15=F.|last16=Ungar|first16=A.|last17=van Dijk|first17=J. G.|last18=Walma|first18=E. P.|last19=Wieling|first19=W.|last20=Abe|first20=H.|last21=Benditt|first21=D. G.|last22=Decker|first22=W. W.|last23=Grubb|first23=B. P.|last24=Kaufmann|first24=H.|last25=Morillo|first25=C.|last26=Olshansky|first26=B.|last27=Parry|first27=S. W.|last28=Sheldon|first28=R.|last29=Shen|first29=W. K.|last30=Vahanian|first30=A.|last31=Auricchio|first31=A.|last32=Bax|first32=J.|last33=Ceconi|first33=C.|last34=Dean|first34=V.|last35=Filippatos|first35=G.|last36=Funck-Brentano|first36=C.|last37=Hobbs|first37=R.|last38=Kearney|first38=P.|last39=McDonagh|first39=T.|last40=McGregor|first40=K.|last41=Popescu|first41=B. A.|last42=Reiner|first42=Z.|last43=Sechtem|first43=U.|last44=Sirnes|first44=P. A.|last45=Tendera|first45=M.|last46=Vardas|first46=P.|last47=Widimsky|first47=P.|last48=Auricchio|first48=A.|last49=Acarturk|first49=E.|last50=Andreotti|first50=F.|last51=Asteggiano|first51=R.|last52=Bauersfeld|first52=U.|last53=Bellou|first53=A.|last54=Benetos|first54=A.|last55=Brandt|first55=J.|last56=Chung|first56=M. K.|last57=Cortelli|first57=P.|last58=Da Costa|first58=A.|last59=Extramiana|first59=F.|last60=Ferro|first60=J.|last61=Gorenek|first61=B.|last62=Hedman|first62=A.|last63=Hirsch|first63=R.|last64=Kaliska|first64=G.|last65=Kenny|first65=R. A.|last66=Kjeldsen|first66=K. P.|last67=Lampert|first67=R.|last68=Molgard|first68=H.|last69=Paju|first69=R.|last70=Puodziukynas|first70=A.|last71=Raviele|first71=A.|last72=Roman|first72=P.|last73=Scherer|first73=M.|last74=Schondorf|first74=R.|last75=Sicari|first75=R.|last76=Vanbrabant|first76=P.|last77=Wolpert|first77=C.|last78=Zamorano|first78=J. L.|title=Guidelines for the diagnosis and management of syncope (version 2009): The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC)|journal=European Heart Journal|volume=30|issue=21|year=2009|pages=2631–2671|issn=0195-668X|doi=10.1093/eurheartj/ehp298}}</ref><ref name="Sutton2013">{{cite journal|last1=Sutton|first1=Richard|title=Clinical Classification of Syncope|journal=Progress in Cardiovascular Diseases|volume=55|issue=4|year=2013|pages=339–344|issn=00330620|doi=10.1016/j.pcad.2012.11.005}}</ref><ref name="PuppalaDickinson2014">{{cite journal|last1=Puppala|first1=Venkata Krishna|last2=Dickinson|first2=Oana|last3=Benditt|first3=David G.|title=Syncope: Classification and risk stratification|journal=Journal of Cardiology|volume=63|issue=3|year=2014|pages=171–177|issn=09145087|doi=10.1016/j.jjcc.2013.03.019}}</ref>
 {| class="wikitable"
 |+
@@ Line 13: / Line 74: @@
 | align="center" style="background: #4479BA; color: #FFFFFF |'''Neurally-Mediated Syncope'''
 |-
-|'''[[Vasovagal]]'''
+|'''[[Vasovagal syncope|Vasovagal]]'''
 |-
 |
@@ Line 88: / Line 149: @@
 |-
 |
-*Tachy arrhythmia:
+*[[Tachyarrhythmia]]:
-**Supraventricular including atrial fibrillation
+**[[Supraventricular tachycardia|Supraventricular]] including [[atrial fibrillation]]
-**Ventricular (idiopathic secondary to structural heart disease, or due to channelopathies)
+**[[Ventricular]] (idiopathic secondary to [[structural heart disease]], or due to channelopathies)
 |-
-|'''Structural heart disease'''
+|'''[[Structural heart disease]]'''
 |-
 |
-*Cardiac:
+*[[Cardiac]]:
-**Cardiac valvular disease
+**[[Valvular heart disease|Cardiac valvular disease]]
-**Acute myocardial infarction/ischemia
+**[[Acute myocardial infarction]]/[[ischemia]]
-**Hypertrophic cardiomyopathy
+**[[Hypertrophic cardiomyopathy]]
-**Cardiac masses (atrial myxoma, tumors, etc.)
+**[[Cardiac]] masses ([[atrial myxoma]], [[Cardiac Tumors|tumors]], etc.)
 |-
 |
-*Pericardial disease:
+*[[Pericardial disease]]:
-**Tamponade
+**[[Cardiac Tamponade|Tamponade]]
-**Congenital anomalies of coronary arteries
+**[[Congenital anomalies]] of [[coronary]] arteries
-**Prosthetic valves dysfunction
+**[[Prosthetic valves]] dysfunction
 |-
-|'''Other cardiovascular:'''
+|'''Other [[cardiovascular]]:'''
 |-
 |
-*Pulmonary embolus
+*[[Pulmonary embolus]]
-*Pulmonary hypertension
+*[[Pulmonary hypertension]]
-*Acute aortic dissection
+*[[Aortic dissection|Acute aortic dissection]]
 |-
 |+
 ! style="background: #4479BA; color: #FFFFFF |'''Conditions Incorrectly Diagnosed as Syncope'''
 |-
-|'''Disorders with partial or complete loss of consciousness'''
+|'''[[Disorders]] with partial or complete [[loss of consciousness]]'''
 |-
 |
-* Epilepsy
+*[[Epilepsy]]
 |-
 |
-* Metabolic disorders:
+*[[Metabolic disorders]]:
-** Hypoglycemia
+**[[Hypoglycemia]]
-** Hypoxia
+**[[Hypoxia]]
 ** Hyperventilation with hypocapnia
 |-
 |
-* Intoxication
+*[[Intoxication]]
 |-
 |
 * Vertebrobasilar TIA
 |-
-|'''Conditions without loss of consciousness'''
+|'''[[Conditions]] without [[loss of consciousness]]'''
 |-
 |
-* Cataplexy
+*[[Cataplexy]]
 |-
 |
-*Falls
+*[[Falls]]
 |-
 |
-*Functional
+*Functional (pseudoscope)
 |-
 |
@@ Line 150: / Line 211: @@
 |-
 |
-*TIA of carotid origin
+*[[TIA]] of carotid origin
 |}
 {|
@@ Line 156: / Line 217: @@
 |-
 |}
-* Vasovagal Syncope
-{{main|Vasovagal syncope}}
-The vasovagal type can be considered in two forms:
-*Isolated episodes of loss of consciousness, unheralded by any warning symptoms for more than a few moments. These tend to occur in the adolescent age group and may be associated with fasting, exercise, abdominal straining or circumstances promoting vaso-dilatation (eg heat, alcohol). The subject is invariably upright. The [[tilt-table test]], if performed, is generally negative.
-*Recurrent syncope with complex associated symptoms. This is the so-called Neurally Mediated Syncope (NMS). It is associated with any of the following: preceding or succeeding sleepiness, preceding visual disturbance ("spots before the eyes"), sweating, light-headedness. The subject is usually but not always upright. The [[tilt-table test]], if performed, is generally positive.
-A pattern of background factors contributes to the attacks. There is typically an unsuspected relatively low blood volume, for instance, from taking a low salt diet in the absence of any salt-retaining tendency. Heat causes vaso-dilatation and worsens the effect of the relatively insufficient blood volume. That sets the scene, but the next stage is the adrenergic response. If there is underlying fear or anxiety (e.g. social circumstances), or acute fear (e.g. acute threat, needle phobia), the vaso-motor center demands an increased pumping action by the heart (flight or fight response). This is set in motion via the adrenergic (sympathetic) outflow from the brain but the heart is unable to meet the requirement because of the low blood volume, or decreased return. The high (ineffective) sympathetic activity is always modulated by vagal outflow, in these cases leading to an excessive slowing of the heart rate. The abnormality lies in this excessive vagal response. The tilt-table test typically evokes the attack.
-Much of this pathway was discovered in animal experiments by Bezold (Vienna) in the 1860s. In animals, it may represent a defense mechanism when confronted by danger ("playing possum"). This reflex occurs only in some people and maybe similar to that described in animals.
-The mechanism described here suggests that a practical way to prevent attacks would be, counter-intuitively, to block the adrenergic signal with a [[beta blocker]]. But, a simpler plan is to explain the mechanism, discuss causes of fear, and optimize salt as well as water intake.
-===Cardiovascular Syncope===
-Cardiovascular syncope includes [[arrhythmia]]s and [[structural heart disease]] as the cause of the loss of consciousnesses. One of the most important aspects, when syncope is diagnosed, is to determine the cause, specially if it is cardiovascular.  A rapid initial evaluation is needed to order the correct diagnostic tests and give the appropriate treatment urgent.
-A pure [[cardiac arrhythmia]] is a serious matter that can appear as syncope but this is unusual. Severe narrowing of the [[aortic valve]] leading to syncope is included for completeness.
-Fainting can also occur if pressure on the carotid artery in the neck triggers a vagal signal to the Vaso-Motor Centre, causing a vagal response reflex to slow the heart.
-===Syncope from Vertebro-basilar Arterial Disease===
-Arterial disease in the upper [[spinal cord]], or lower [[brain]], causes syncope if there is a reduction in blood supply, which may occur with extending the neck or after drugs to lower [[blood pressure]].
 ==References==
@@ Line 186: / Line 225: @@
 [[Category:Cardiology]]
 [[Category:Neurology]]
-[[Category:Nutrition]]
+[[Category:Up To Date]]
-[[Category:Metabolic disorders]]
-[[Category:Primary care]]
-{{WikiDoc Help Menu}}
-{{WikiDoc Sources}}

Syncope classification: Difference between revisions

Latest revision as of 14:02, 15 December 2021

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