Transcript PACEMAKER TİPLERİ , MODLARI VE HASTA TAKİBİ

SYNCOPE
Rasim Enar, M.D.
Professor of Cardiology
İstanbul University – Cerrahpaşa Medical Faculty
Department of Cardiology
Neuro- Cardiogenic Syncope
Neuro- Cardiogenic Syncope
Syncope - Definition
• Syncope; is a transient loss of conciousness and
postural tone with spontaneous recovery
• Loss of consiousness is a result of ,
sudden and shorterm serebral hipoperfusion
• Restoration of conciousness or orientation after a
syncopal episode is usually immediate, and
does nor require electrical or chemical therapy
for reversal
Neurocardiogenic Syncope
Prevelans
• 1- 6 % of all hospital admissions
• 3 % of Emergency Department visits
Prognosis – 1 year mortality risc
• Cardiogenic Syncope
: 24 %
• Non-Cardiogenic Syncope : 4 %
Neurocardiogenic Syncope
Etiology – Cardiac Causes
Anatomic causes
Aortic stenosis
HOCM
Myocardial ischemia / infarction
Aortic dissection
Cardiac tamponade
Atrial myxoma
Severe pulmonary hypertension
Severe pulmonary emboli
Subclavian steal syndrome
Fallot tetralogy
Arrhythmic causes
Tachy-arrhythmias
- Supraventricular tachycardia
- Ventricular tachycardia
- Long-QT syndrome (primary /secondary)
- Brugada syndrome
Brady-arrythmia
- Atrioventricular block
- Pace-maker dysfunction
- ICD dysfunction
- Sinus node dysfunction / bradycardia
Sick Sinus Syndrome
Neurocardiogenic Syncope
“Primary Evaluation”
• Detailed clinical history obtained from the patient or
the witness of the syncopal episode, about the period
just before or after the episode will give clues about
the etiology
• Ortostatic blood pressure measurements and careful
physical examination including oscultation of
cardiac murmurs and carotis bruits
• Standart ECG
Neurocardiogenic Syncope
Classification of syncope
• Neurocardiogenic syndromes
e.g. vasovagal, carotid sinus hypersensitivity, situational
• Ortostatic
• Primary cause : cardiac arrhythmia – conduction
disturbances
e.g. Bradycardia, Tachycardia, AV-Block, etc
• Structural cardiac or cardiopulmonary diseases
e.g. acute myocardial infarction, aortic dissection,
acute pulmonary emboli, etc
Neuro- Cardiogenic Syncope
Non-syncope seizures
• Syncope-like conditions, with loss or impairment of
consciousness
e.g. epileptic seizures, TIA, etc
• Syncope-like conditions, where the patient is conscious
e.g. Psycogenic syncope (histerical, somatization disorders), etc
Neuro- Cardiogenic Syncope
Clinical features associated with non-syncope seizure
• Post-seizure >5 min confusion
(epileptic seizure)
• Long lasting tonic-clonic movements with the onset of
the seizure
(epileptic seizure)
• Frequent somatic complaints without accompanying
organic heart disease
(psycogenic)
• Vertigo, dizartria, diplopia (Transient Ischemic Attack)
Neuro- Cardiogenic Syncope
Diagnostic Criteria – Certain (I)
Vasovagal syncope; Syncope with typical prodromal symptoms
which is provoked with fear, severe pain, emotional stress, catheter
instrumentation, or after prolonged standing in hot enviorement
Situational syncope; Syncope produced with vagal stimuli, like
diüresis, frequeny coughing, defecation or swollowing
Ortostatic syncope; Syncope or presyncope associated withg
documented ortostatic hipotension
(Sudden fall of SBP > 20 mmHg or < 90 mmHg)
Neuro- Cardiogenic Syncope
Diagnostic Criteria – Certain (II)
Syncope secondary to cardiac ischemia;
ECG documentation of acute ischemia or infarction
Syncope secondary to cardiac arrhythmia ;
ECG documentation of
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•
•
•
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Sinüs bradycardia (< 40 beat/min or repetitive sinoatrial
block or sinus pause > 3 second)
Atrioventriküler block (2nd degree Mobitz Type II or
3rd degree)
Alternating LBBB or RBBB
Rapid paroxismal supraventricular tachycardia or ventricular
tachtcardia
Pace-maker dysfunction associated with cardiac pause
Neuro- Cardiogenic Syncope
Diagnostic Criteria - Probable
Conditions related with CARDIAC syncope ;
• Supine
• Post egzersize
• Post palpitation
• Known serious organic heart disease
• ECG disturbances
- wide QRS complex (>0.12 sec)
- AV conduction disturbances
- Post-meal at 1 hour
- Post egzersize
- Following with new drug administration or
after change of the dose
June 2004
Neuro - Cardiogenic Syncope
Neuro- Cardiogenic Syncope
Which patients should be hospitalised
• Syncope secondary to a cardiac pathology
• Syncope resulted with serious injury
• Frequent syncope attacks
Neuro- Cardiogenic Syncope
Diagnostic Tests
• Carotid Sinus Massage
• Tilt Table Test
• Holter monitorörization
• Echocardiyography
• Egzersize Test
• External or Internal Loop Recorders
• Electrophysiologic Study (EPS)
• Cardiac Catheterisation and coronary anjiography
• Neurologic and pschchiatric evaluation
Neuro- Cardiogenic Syncope
Syncope (unknown etiology)
History, Physical Exam, ECG
Probable
Diagnosis (10%)
Spesific tests
Unclassified syncope
(60%)
Echocardiography
Organic Heart Disease / Arrhythmia ?
EPS
Diagnosis (+)
Spesific tx & F/U
Definite
Diagnosis (10%)
Spesific treatment & F/U
Vazovagal syncope ?
Tilt Table Test
Diagnosis (-)
Holter / Tilt TT
Diagnosis (+)
Spesific tx & F/U
Diagnosis (-)
Holter / Tilt TT
Olası
SENKOP
Hikaye,FM,
EKG
OLASI
(?)
TEŞHİS
(+)
TEŞHİS
(-)
OLASI
SENKOP
SSS
hastalığı
(TİA,subklav
yan çalma,
migren,
nöbet
olasılığı,
fokal
nörolojik
bulgular.
EEG,
Serebral CT,
Serebral aklım
çalışması,
Anjiyografi.
Karotissinüs
Senkopu
Azalmış Kalp Debisi
(SĞV,SV çıkış yolu
obstrüksdiyonu,Mİ.
Karotis
masajı
Ekokardiyografi:
Kardiyak katereizasyon,
CPK-MB,gelişte,
Akc görüntüleme,
pulmoner anjiyo.
Pulmoner
Emboli
emboli
Kalp hastalığı (-)
NEGATİF
Kalp
hastalığı
(+)
BİR
EPİSOD:
 Holter
mont.
 EFÇ: ().
 Tilttesti
 Tilttesti.
 ?Holter.
TEKRARLAYAN
SENKOP:
 Tilt-test
 Psikiyatrik
tetkik.
 Holter.
 Loopkaydedici.