Fainting/syncope

Syncope, commonly known as fainting, is a temporary loss of consciousness and postural tone due to transient cerebral hypoperfusion. It’s a common clinical problem and can be caused by a variety of factors.

Causes of Syncope:

  • Vasovagal Syncope: Triggered by prolonged standing, emotional stress, pain, or heat exposure.
  • Orthostatic Hypotension: Sudden drop in blood pressure upon standing, due to dehydration, medications, or autonomic dysfunction.
  • Cardiac Syncope: Arrhythmias (bradycardia or tachycardia), structural heart disease (aortic stenosis, hypertrophic cardiomyopathy), or ischemic heart disease.
  • Neurological Causes: Transient ischemic attacks, vertebrobasilar insufficiency.
  • Metabolic and Other Causes: Hypoglycemia, hyperventilation, anemia.

Diagnosis:

  • History:
    • Onset and Duration: Abruptness, duration of unconsciousness.
    • Precipitating Factors: Position changes, stress, pain, eating, cough, exertion.
    • Associated Symptoms: Palpitations, chest pain, shortness of breath, neurological symptoms, incontinence, seizures
    • Past Medical History: Cardiovascular, neurological disorders, diabetes, medication use.
    • Family History: Of syncope or sudden cardiac death.
  • Physical Examination:
    • Vital Signs: Blood pressure (in different positions), heart rate.
    • Cardiovascular Exam: Heart murmurs, irregular heartbeats, signs of heart failure.
    • Neurological Exam: Focal deficits, gait abnormalities.
    • ENT Examination: To rule out vestibular causes.
  • Investigations:
    • Electrocardiogram (ECG): To detect arrhythmias or ischemic changes.
    • Echocardiogram: If structural heart disease is suspected.
    • Blood Tests: CBC, electrolytes, glucose, renal function.
    • Tilt Table Test: If vasovagal or orthostatic syncope is suspected.
    • Holter Monitoring or Event Recorder: For suspected arrhythmic causes.
    • Neurological Investigations: CT/MRI of the head, carotid ultrasound, if a neurological cause is suspected.

Differential Diagnosis (DDx):

  • Seizure Disorders
  • Transient Ischemic Attack (TIA)
  • Hypoglycemia
  • Psychogenic Pseudosyncope
  • Vertigo

Management:

  • General Measures:
    • Education and Avoidance of Triggers: For vasovagal syncope.
    • Hydration and Salt Intake: To manage orthostatic hypotension.
    • Review and Adjust Medications: That could contribute to syncope.
  • Specific Treatment Based on Cause:
    • Vasovagal Syncope: Patient education, physical counterpressure maneuvers.
    • Orthostatic Hypotension: Fludrocortisone, midodrine, compression stockings.
    • Cardiac Syncope: Pacemaker for bradycardia, anti-arrhythmic drugs, correction of structural abnormalities.
    • Neurological Causes: Addressing the specific neurological condition.
  • Lifestyle Modifications:
    • Avoiding Dehydration and Alcohol
    • Gradual Position Changes
    • Adequate Nutrition

Follow-Up and Monitoring:

  • Regular Follow-up: Especially if on medication or with cardiac/neurological causes.
  • Monitoring for Recurrence: Patient education on recognizing prodromal symptoms.
  • Driving Restrictions

Referral:

  • Cardiologist or Electrophysiologist: For suspected cardiac syncope.
  • Neurologist: If a neurological cause is suspected.

Managing syncope effectively requires a tailored approach based on the underlying cause, the patient’s overall health, and the risk of recurrence or serious outcomes.