Syncope: An Evidence-Based Approach

Foreword
Preface
	Rationale for the Second Edition
	Aims and Scope
Contents
Part I: TLOC/Collapse: Pathophysiologic and Epidemiologic Features
	Chapter 1: Syncope: Definition and Classification-Contrasting the American and European Guidelines
		1.1 What Is Consciousness?
		1.2 Transient Loss of Consciousness
		1.3 Terminology
		1.4 Syncope: Definitions
		1.5 What Caused the “Spell”?
		1.6 Classification
			1.6.1 Reflex (Neurally-Mediated) Syncope
			1.6.2 Orthostatic Hypotension-Induced Syncope
			1.6.3 Cardiac Syncope
			1.6.4 Syncope of Unknown Origin
		1.7 Problems with Classification
		1.8 Gaps Remain
		1.9 Conclusion
		References
	Chapter 2: The Meaning of ‘Consciousness’ in Syncope and Related Disorders
		2.1 Different Meanings and Aspects of ‘Consciousness’
			2.1.1 Dictionary Definitions
			2.1.2 The Medical Context: Content and Arousal
			2.1.3 Normal States of Consciousness
			2.1.4 Abnormal States of Consciousness
			2.1.5 Networks of Arousal and Awareness
		2.2 Consciousness in the Medical Context of TLOC
			2.2.1 Differences between the European and North American Guidelines
			2.2.2 The Four Defining Features of TLOC
		2.3 Specific Disorders Causing LOC
			2.3.1 LOC in the Distinction between Syncope and TIA
			2.3.2 Focal Signs in Syncope
			2.3.3 LOC in TIA and Stroke
			2.3.4 LOC in Syncope
			2.3.5 LOC in Epilepsy
			2.3.6 LOC in Psychogenic TLOC
		2.4 Conclusions
		References
	Chapter 3: Prognosis of Syncope Across the Diagnostic Spectrum
		3.1 Introduction
		3.2 What Is Prognosis in the Context of Syncope?
		3.3 Determinants of Prognosis in Syncope
		3.4 Short-Term Prognosis in Syncope
		3.5 Long-Term Prognosis
		3.6 Syncope Recurrence
		3.7 New Developments in Syncope Prognosis?
		3.8 Prognostication in Syncope: Dark Art or Science?
		3.9 What Makes Perfect Prognostication? Recommendations and Conclusions
		References
	Chapter 4: The Economic Impact of Syncope: Direct and Indirect Costs
		4.1 Introduction
		4.2 Syncope Burden
		4.3 Direct Economic Costs
			4.3.1 USA
			4.3.2 Europe
			4.3.3 Unexplained Syncope
		4.4 Indirect Economic Costs
		4.5 Strategies to Reduce Cost
			4.5.1 Emergency Department Risk Stratification
			4.5.2 Adherence to a Standardized Approach
			4.5.3 The Syncope Unit
			4.5.4 Implantable Loop Recorders (Insertable Cardiac Monitors)
			4.5.5 Conclusion
		References
Part II: Basic Clinical Features
	Chapter 5: Determining the Cause of TLOC/Collapse: The Initial Evaluation
		5.1 Introduction
		5.2 Definition and Classification of TLOC
		5.3 Causes of TLOC
		5.4 Initial Evaluation of TLOC
		5.5 Recognizing the Cause of TLOC
		5.6 Risk Stratification
		5.7 Summary
		References
	Chapter 6: Seizures vs Syncope: Distinguishing Features for the Clinic
		6.1 Introduction
		6.2 Epileptic Seizures, Convulsive Syncope, and the Guidelines
		6.3 Epidemiology
		6.4 Useful Features in the History
		6.5 Tilt Tests for Questionable Epilepsy
		6.6 Neurologic Investigations
		6.7 Video Recordings
		6.8 Implantable Cardiac Monitors for Questionable Epilepsy
		6.9 Conclusions: A Practical and Efficient Approach
		References
	Chapter 7: Reflex Syncope: The Common and Less Common Variants
		7.1 Introduction
		7.2 Types of Reflex Syncope
			7.2.1 Vasovagal Syncope (VVS)
				7.2.1.1 Clinical Features
				7.2.1.2 Pathophysiology
				7.2.1.3 Diagnosis
				7.2.1.4 VVS Treatment
			7.2.2 Carotid Sinus Syndrome
				7.2.2.1 Clinical Features
				7.2.2.2 Treatment
			7.2.3 Situational Syncope
				7.2.3.1 Clinical Features and Pathophysiology
				7.2.3.2 Micturition Syncope
				7.2.3.3 Defecation Syncope
				7.2.3.4 Swallow (Deglutition) Syncope
				7.2.3.5 Cough Syncope
				7.2.3.6 Laugh (Gelastic) Syncope
				7.2.3.7 Situational Syncope Diagnosis
				7.2.3.8 Situational Syncope Treatment
		7.3 Conclusion
		References
	Chapter 8: Orthostatic Hypotension Variants, POTS, and Less Well-Defined Autonomic Dysfunction
		8.1 Introduction
			8.1.1 Orthostatic Hypotension
			8.1.2 Postural Orthostatic Tachycardia Syndrome (POTS)
			8.1.3 Other Syndromes of Autonomic Dysfunction
		8.2 Conclusions
		References
	Chapter 9: Bradycardias and Tachycardias: Acquired and Inheritable
		9.1 Introduction
		9.2 Bradycardias and Tachycardias: Acquired and Inheritable
			9.2.1 Clinical Features of Syncope Due to Arrhythmias
		9.3 Bradyarrhythmias
		9.4 Acquired Bradyarrhythmias
		9.5 Inherited Bradyarrhythmias
		9.6 Tachyarrhythmias
		9.7 Monomorphic and Polymorphic VT
		9.8 Inherited Arrhythmia Syndromes
		9.9 Long QT Syndrome
		9.10 Brugada Syndrome
		9.11 Catecholaminergic Polymorphic Ventricular Tachycardia
		9.12 Other Forms of Inherited Arrhythmia
		9.13 Screening for Inherited Arrhythmias
		9.14 Conclusion
		References
	Chapter 10: Differential Diagnosis of Autonomic Disturbances and Recognition by History and Physical Findings
		10.1 Introduction
		10.2 Clinical Presentation
		10.3 Neurodegenerative Autonomic Failure Syndromes
			10.3.1 Multisystem Atrophy (MSA)
			10.3.2 Pure Autonomic Failure
			10.3.3 Parkinson’s Disease (PD)
			10.3.4 Dementia with Lewy Bodies
		10.4 Autonomic Peripheral Neuropathies
			10.4.1 Autoimmune Autonomic Ganglionopathy
			10.4.2 Paraneoplastic Syndromes
		10.5 Conclusions
		References
	Chapter 11: Psychogenic Pseudosyncope and Pseudoseizure: Approach and Treatment
		11.1 Introduction
		11.2 PPS and PNES History of Evolution of Thought
		11.3 Diagnostic Classification
		11.4 Psychogenic Pseudosyncope (PPS)
		11.5 Psychogenic Nonepileptic Seizure (PNES)
			11.5.1 Possible PNES
			11.5.2 Probable PNES
			11.5.3 Clinically Established PNES
			11.5.4 Documented PNES
		11.6 Management of PPS/PNES
			11.6.1 The Diagnostic Process
			11.6.2 Communicating the Diagnosis
			11.6.3 Treatment of PPS/PNES
		11.7 Conclusions
		References
Part III: Basic Diagnostic Strategies
	Chapter 12: Managing Syncope/Collapse in the Emergency Department
		12.1 Has My Patient Had Syncope?
		12.2 How Should I Approach the Patient with Syncope?
		12.3 Risk Assessment
		12.4 Clinical Decision Rules
		12.5 Biomarkers
		12.6 Red Flag Features not to Be Missed
		12.7 Does My Patient Need to Be Admitted to Hospital?
		12.8 How Should I ECG Monitor My Patient?
		12.9 Driving
		12.10 Should My Hospital Have a Syncope Clinical Decision Unit?
		12.11 Should My Hospital Have a Rapid Access Syncope Clinic?
		12.12 Conclusion
		References
	Chapter 13: TLOC/Collapse: The Role of the Emergency Department Observation Unit
		13.1 Introduction
		13.2 Syncope Observation Unit and Its Role in Managing Syncope
		13.3 Management of Syncope in the Emergency Department Syncope Observation Unit, According to Risk Stratification
			13.3.1 Mandatory Steps
			13.3.2 Optional Steps
		13.4 SOU Organization
		13.5 Syncope Observation Unit and Syncope Unit
		13.6 Conclusion
		References
	Chapter 14: Ambulatory ECG Monitoring in Syncope and Collapse: Current Status and Utility
		14.1 Introduction
		14.2 Physician Practice Findings
			14.2.1 US Physician Observations
			14.2.2 European Observations
			14.2.3 Factors Driving Monitor Technology Choice in Europe
		14.3 Follow-Up AECG Monitoring by US and European Physicians
		14.4 Patient Understanding of AECG Use
		14.5 Conclusion
		References
	Chapter 15: Carotid Sinus Syndrome: Pathophysiology and Diagnosis
		15.1 Anatomy and Physiology
		15.2 Pathophysiology
			15.2.1 Epidemiology of CSH
			15.2.2 Etiology
		15.3 Carotid Sinus Hypersensitivity and Carotid Sinus Syndrome
			15.3.1 Cause and Effect Relationship Between Carotid Sinus Massage and Syncope
			15.3.2 Epidemiology of CSS
		15.4 Diagnosis of Carotid Sinus Syndrome
			15.4.1 Methodology of CSM
			15.4.2 Complications of CSM
		15.5 Conclusion
		References
	Chapter 16: Electrophysiology Testing: Appropriate Indications in TLOC/Collapse
		16.1 Introduction
		16.2 EPS Indications in Syncope
		16.3 EPS Techniques
		16.4 Basic Electrophysiology Study Protocol for Evaluation of Syncope
		16.5 Assessment of Sinus Node Dysfunction
			16.5.1 EPS and Conduction System Disease
			16.5.2 Supraventricular Tachycardia
			16.5.3 Ventricular Tachycardia
			16.5.4 Ablation of Arrhythmias
			16.5.5 Inconclusive EPS Despite Suspicion of an Arrhythmic Cause of Syncope
		16.6 Conclusion
		References
	Chapter 17: The Syncope Evaluation Unit: Essential Features, Current Status
		17.1 Epidemiology and Current Practice
		17.2 Rationale for a Syncope Unit
		17.3 Essential Requirements for a Syncope Unit
		17.4 Syncope Units Models
		17.5 Follow-up and Outcome
		17.6 Future Perspectives
		17.7 Summary
		References
Part IV: Selected Testing: When and How
	Chapter 18: Role of Head and Cardiac Imaging, and Cardiac Stress Testing for Syncope
		18.1 Introduction
		18.2 Role of Head Imaging
		18.3 Role of Cardiac Imaging
		18.4 Role of Cardiac Stress Testing
		18.5 Conclusion
		References
	Chapter 19: The Autonomic Laboratory for Evaluating Syncope/Collapse: Investigations and Their Implications
		19.1 Introduction
			19.1.1 Clinical Evaluation
			19.1.2 Autonomic Investigations
			19.1.3 Conclusion
		References
	Chapter 20: Utility of Video-EEG for Diagnosing and Understanding Transient Loss of Consciousness
		20.1 Introduction
		20.2 Syncope
			20.2.1 Reflex Syncope
			20.2.2 Orthostatic Hypotension
			20.2.3 Cardiac Syncope
		20.3 Epileptic Seizures
		20.4 Psychogenic Transient Loss of Consciousness
			20.4.1 Psychogenic Non-epileptic Seizures
		20.5 Equipment
		20.6 Conclusion
		References
Part V: Treatment Considerations
	Chapter 21: Indications for Pacing in Patients With Unexplained Syncope and Bifascicular Block
		21.1 Introduction
		21.2 Conclusions
		References
	Chapter 22: Unexplained Syncope in Patients with High Risk of Sudden Death
		22.1 Introduction
		22.2 Classification of Syncope
		22.3 ICD Therapy for the Syncope Patient
		22.4 Impact of Syncope in the Cardiomyopathy Patient and Its Relationship to Sudden Death
		22.5 Arrhythmic Conditions with Underlying Structural Disease
			22.5.1 Hypertrophic Cardiomyopathy (HCM)
			22.5.2 Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)
			22.5.3 Long QT Syndrome
			22.5.4 Brugada Syndrome
			22.5.5 Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)
		22.6 A Clinicians Observations on the ACC/AHA/HRS and ESC Syncope Guidelines
		References
	Chapter 23: Non-Pharmacological and Pharmacological Therapies in Vasovagal Syncope: Current Status
		23.1 Introduction
		23.2 Discontinuation of Blood Pressure Lowering Medications in VVS
			23.2.1 The Guidelines Speak
			23.2.2 Commentary
		23.3 Non-Pharmacological Therapies for VVS
			23.3.1 Water and Salt Intake
				23.3.1.1 The Guidelines Speak
				23.3.1.2 Commentary
			23.3.2 Physical Counter-Pressure Maneuvers
				23.3.2.1 The Guidelines Speak
				23.3.2.2 Commentary
		23.4 Pharmacological Therapies for VVS
			23.4.1 Alpha-1 Agonists
				23.4.1.1 The Guidelines Speak
				23.4.1.2 Commentary
			23.4.2 Fludrocortisone
				23.4.2.1 The Guidelines Speak
				23.4.2.2 Commentary
			23.4.3 Beta-Blockers
				23.4.3.1 The Guidelines Speak
				23.4.3.2 Commentary
			23.4.4 Selective Serotonin Reuptake Inhibitors
				23.4.4.1 The Guidelines Speak
				23.4.4.2 Commentary
			23.4.5 Theophylline
				23.4.5.1 The Guidelines Don’t Speak
				23.4.5.2 Commentary
			23.4.6 Norepinephrine Transport (NET) Inhibitors
				23.4.6.1 The Guidelines Don’t Speak
				23.4.6.2 Commentary
		23.5 Conclusions
		References
	Chapter 24: Update on Cardiac Pacing in Reflex Syncope
		24.1 Introduction
		24.2 Vasovagal Syncope
			24.2.1 Studies on Pacing in Vasovagal Syncope
			24.2.2 Guideline Recommendations for Pacing in Vasovagal Syncope
		24.3 Carotid Sinus Syndrome
			24.3.1 Studies on Pacing in Carotid Sinus Syndrome
			24.3.2 Guideline Recommendations for Pacing in Carotid Sinus Syndrome
		24.4 Low-Adenosine Syncope
		24.5 Choice of Pacing Mode
		24.6 Diagnostic Algorithm for Decision on Cardiac Pacing in Reflex Syncope
		24.7 Future Direction
		24.8 Summary and Key Points
		References
	Chapter 25: Ictal Asystole: Relation to Reflex Syncope and Role of Cardiac Pacing
		25.1 Introduction
		25.2 Asystolic Reflex Syncope
		25.3 Asystole in Patients with Temporal Lobe Epilepsy
		25.4 Pathophysiology of Ictal Asystole
		25.5 ECG Findings in Cardioinhibitory Vasovagal Syncope and Ictal Asystole
		25.6 Role of Cardiac Pacing for Ictal Asystole
		25.7 Conclusions
		References
	Chapter 26: Cardioneuroablation for Cardioinhibitory Vasovagal Syncope
		26.1 Introduction
		26.2 Anatomic Basis of Cardiac Neural Control
		26.3 Neruomodulation Therapy in Cardiac Disease
		26.4 Neuromodulation/Cardioneuroablation in Vasovagal Syncope
			26.4.1 Approach to Cardioneuroablation for VVS
			26.4.2 Future Perspectives for Cardioneuroablation in VVS
		26.5 Conclusion
		References
	Chapter 27: Driving and Flying: US and European Recommendations
		27.1 Introduction
		27.2 Driving
			27.2.1 Legal Aspects
			27.2.2 Private Vs. Commercial Driving
			27.2.3 Determining “Acceptable” Risk
			27.2.4 Vasovagal Syncope and Syncope of Unknown Origin
				27.2.4.1 Group 1 Drivers: Summary
				27.2.4.2 Group 2 Drivers: Summary
				27.2.4.3 Discussion
			27.2.5 Ventricular Arrhythmias and Defibrillators
				27.2.5.1 Group 1 Drivers: Summary
				27.2.5.2 Group 2 Drivers: Summary
				27.2.5.3 Discussion
			27.2.6 Other Arrhythmias Causing Syncope [3, 4, 6–9, 11, 13]
		27.3 Flying/Piloting an Aircraft
			27.3.1 Determining “Acceptable” Risk: The 1% Rule
		27.4 Summary
		References
Index