An individual that has experienced a cardiogenic syncope may describe the presence of an aura prior to the event, consisting of dizziness, amaurosis, diaphoresis, nausea or blurred vision. The duration of the aura is different in various cases, depending on the mechanism of the disease. If the substrate is arrhythmic, the aura lasts for about 3 seconds, whereas in vasovagal episodes its duration may be as long as 2.5 minutes. This period is followed by a complete, short duration loss of consciousness. Convulsions, myoclonic jerks or tonic spasms caused by brain hypoperfusion [1] may occur during the episode. Urine and fecal matter loss, confusion and oral trauma suggest epilepsy, whereas dysarthria and focal neurologic signs imply cerebrovascular disease. The recovery after a cardiogenic syncope is usually complete and spontaneous.

• Falling

  Injuries from a fall can be serious, so if you know you’re prone to these episodes, take steps to reduce your risk of falling. [baptisthealth.com]

  Other episodes of psychomotor type occurred in subsequent days, but there were no falls or tonic convulsions. [jnnp.bmj.com]

  Indeed, the heart rate increases slowly as the arterial pressure falls. [courses.washington.edu]

  This relatively benign cause may, however, lead to life-threatening injuries as a result of falls. [amboss.com]

  This is followed by a gradual fall in both arterial pressure and cardiac filling. [ahajournals.org]

• Amyloidosis

  Infiltrating diseases like amyloidosis, hypothyroid states can result in SND. Drug induced SND like beta blocker and calcium blockers are fairly common and should be excluded Some congenital heart disease (SVC ASD) can involve sinus node. [drsvenkatesan.com]

  Orthostatic hypotension (postural hypotension) - syncope occurs after standing up: Autonomic failure: Multiple system atrophy, Parkinson's disease, diabetic neuropathy, amyloidosis. Medications - eg, antihypertensives. Post-exercise. Postprandial. [patient.info]

  Secondary dysfunctions occur by changes of aging, due to the involvement of the peripheral nervous system in diabetes mellitus, renal failure, alcoholism, amyloidosis; infections of the nervous system by Chagas disease, human immunodeficiency virus; metabolic [frontiersin.org]

  Systemic illness that affects multiple organs (eg, cancer, diabetes mellitus, amyloidosis, and renal failure) may disturb autonomic function to a degree that orthostatic hypotension and syncope occur. [ahajournals.org]

• Surgical Procedure

  It is highly possible that, in the patients who received pacemakers, the surgical procedure itself, rather than cardiac pacing, was enough to create a placebo effect in decreasing the recurrence of syncope. [innovationsincrm.com]

• Yawning

  • Pale skin • Dizziness or lightheadedness • Tunnel vision-which means a person’s field of vision is so constricted that he or she can only see what is in front of them • Slow, weak pulse • Jerky and/or abnormal movements • Nausea • Blurry vision • Yawning [eatingdisorders.com]

  Lightheadediness, yawning, sleepiness dizziness pallor on standing and specially resting provoks sleepiness. I have never passed out in the common sense of the term. No palpitation or chest pain until this year. [healthunlocked.com]

  Other symptoms that may occur before fainting include feeling either warm or cold, tremors, yawning and having a bluish/purple or red coloring to the skin, or looking very pale or grey. During fainting, “seizure-like” activity may occur. [pccoforegon.com]

  Symptoms Before you faint due to vasovagal syncope, you may experience some of the following: Pale skin Lightheadedness Tunnel vision — your field of vision narrows so that you see only what's in front of you Nausea Feeling warm A cold, clammy sweat Yawning [mayoclinic.org]

• Sneezing

  Related terms and conditions include situational fainting such as cough, micturitional, defecation, diving, sneezing, and swallowing syncope, carotid sinus syncope (shaving syncope), and autonomic conditions including hyperadrenergic and hypoadrenergic [vumc.org]

  Situational syncope - eg, cough, sneeze, gastrointestinal stimulation (swallowing, defecation, visceral pain), micturition. [patient.info]

• Abdominal Pain

  They may complain of symptoms including nausea, abdominal pain, clamminess, tremors, lightheadedness, headache, malaise, exhaustion and confusion. [pccoforegon.com]

  He denies any chest pain, pressure or discomfort; difficulty breathing; weakness; or headache, back or abdominal pain during this event, and says he is complaint-free and feels fine now. [emsworld.com]

  […] swings in body temperature, nausea, abdominal pain, GI problems, muscle aches or pains, fatigue, depression, inappropriate or exaggerated emotional responses, to name a few. [livingwithncs.wordpress.com]

  Prodromes of nausea, vomiting, abdominal pain, diaphoresis, pallor, palpitations, and dizziness may occur and are more common in young people. After loss of consciousness, tonic-clonic contractions, if they occur, are of short duration (<15 s). [frontiersin.org]

• Failure to Thrive

  We report an 18 month-old girl who presented with recurrent syncope as well as dyspnea, failure to thrive, and frequent episodes of pulmonary infections, suggesting congestive heart failure. [ncbi.nlm.nih.gov]

• Carotid Bruit

  A carotid sinus massage should only be performed by an experienced physician since it can induce prolonged cardiac pauses or severe bradycardia. The maneuver is to be avoided if carotid bruits are present. [symptoma.com]

  Other important features of the physical examination include neurologic findings such as diplopia, dysarthria, nystagmus, ataxia and pupillary asymmetry, as well as cardiac findings such as carotid bruit, jugular venous distension, rales, a systolic murmur [vumc.org]

  Carotid sinus massage should be avoided in patients with previous transient ischaemic attack, stroke within the preceding three months, or with a carotid bruit, except if carotid Doppler studies excluded significant stenosis. [ 1 ] Cardiac syncope: [ [patient.info]

  Carotid sinus pressure should not be applied if a carotid bruit is present. Abdomen is palpated for tenderness, and a rectal examination is done to check for gross or occult blood. [msdmanuals.com]

• Heart Murmur

  The heart is auscultated for murmurs; if present, any change in the murmur with a Valsalva maneuver, standing, or squatting is noted. [msdmanuals.com]

  Neither heart murmur nor crackles were noted. Lower leg edema was not observed. ECG revealed atrial fibrillation, showing a heart rate of 90–100 bpm without ST-T wave abnormalities. [jtd.amegroups.com]

  Use of either recreational illicit drugs or performance-enhancing substances should be excluded. 21 In addition to assessing general appearance and obtaining vital signs, a vigilant physical exam including auscultation for heart murmurs with special maneuvers [acc.org]

• Fracture

  Complications The most serious potential complication of neurocardiogenic syncope is an injury sustained during a fall, such as a concussion or fracture. [baptisthealth.com]

  […] unspecified 2016 2017 2018 2019 Billable/Specific Code Applicable To Heart block NOS Stokes-Adams syndrome I45.9 ) unconsciousness NOS ( ICD-10-CM Diagnosis Code R40.2 Coma 2016 2017 2018 2019 Non-Billable/Non-Specific Code Code First any associated: fracture [icd10data.com]

  Morbidity is particularly high in the elderly and includes loss of confidence, reduced mobility, depressive illness, fear of falling, fractures and subsequent institutionalisation. [patient.info]

  Orthostatic Hypotension Orthostatic or postural hypotension (OH) presents as falls, dizziness, or syncope, resulting in functional impairment, with head injury, bone fractures and hospitalization. [frontiersin.org]

  […] recovery.1-3 It is a common and potentially disabling incident that may be associated with a risk of sudden death.4,5 In 30% of patients, recurrent syncopal episodes have been reported, which may lead to increased morbidity (i.e., lacerations, contusions, fractures [uspharmacist.com]

• Hyperhidrosis

  It can present with a prolonged prodrome characterized by dizziness, fatigue, weakness, palpitations, hearing and vision disturbances, hyperhidrosis, low back pain, neck or precordial pain; followed by rapid syncope.1 Postural (orthostatic) tachycardia [clevelandclinicmeded.com]

• Urinary Retention

  retention Use fludrohydrocortisone in pediatric population with severe vasovagal syncope Consider permanent cardiac pacemakers in patients with asystole during tilt table testing Carotid sinus syndrome Limit the use of tight collars or activities that [clevelandclinicmeded.com]

  In men, the earliest symptoms are impotence and loss of libido, whereas in women, urinary retention and incontinence occur first. [ahajournals.org]

  Disopyramide, a class Ia antiarrhythmic agent with anticholinergic and negative inotropic effects, is not considered first line treatment because of the risk of proarrhythmic and anticholinergic side effects (dry mouth, constipation, blurred vision, and urinary [ncbi.nlm.nih.gov]

• Dizziness

  Vertigo, dizziness, and imbalance rank amongst the most common presenting symptoms in neurology, ENT, geriatric medicine, and general practice. [books.google.com]

  dizziness,? which generally refers to an alteration in balance, vision, or perception of the environment, without the loss of consciousness. [dysautonomiainternational.org]

  The patient that had been presenting asystole and syncope in the first tilt-test presented only dizziness in the follow-up tilt-test. [academic.oup.com]

  He began experiencing medical difficulties including sleeping problems, dizziness and headaches due to blood vessel dilation. [benglasslaw.com]

• Seizure

  However, simultaneous ECG-EEG recording of a tonic seizure could not be obtained. [jnnp.bmj.com]

  Relations between syncope, seizure, and arrhythmia. There are clinically important relations between syncope and seizure disorders. [ncbi.nlm.nih.gov]

• Giddiness

  See also separate Dizziness, Giddiness and Feeling Faint article. [patient.info]

A careful history inquiry is a key tool in evaluating a syncope patient [2]. It should always be combined with clinical examination and a 12 lead electrocardiogram (class A recommendations [3]). The victim should be asked about the position of the body before symptoms set in [4] [5], the activity he or she was involved in and other precipitating factors. Anamnesis should determine if the person has a history of myocardial infarction, structural heart disease, arrhythmia, channelopathy or cardiomyopathy. Prior medication (diuretics, beta blockers, vasodilators, nitrates, antiarrhythmic, tricyclic antidepressants) is always important to know.

The physical evaluation must highlight the vital signs and heart auscultation. Tachycardia is suggestive for an acute cardiovascular event, such as a myocardial infarction, pulmonary embolism or signifies an ongoing tachyarrhythmia. An acute coronary syndrome may also be accompanied by bradycardia, especially if a cardiac conduction defect is present. Murmurs also point to a cardiac cause of the syncope but do not warrant it. Cardiovascular evaluation should be completed by assessment of the jugular veins, auscultation of lung rales, palpation of the liver and possible abdominal masses signifying abdominal aneurysms and evaluation of peripheral edema.

A Schellong test is a useful maneuver, indicating orthostatic hypotension if positive. A carotid sinus massage should only be performed by an experienced physician since it can induce prolonged cardiac pauses or severe bradycardia. The maneuver is to be avoided if carotid bruits are present.

Multiple recurrences during a short period of time require immediate cause diagnosis and therapeutic intervention.

Blood workup is nonspecific in this disease, but certain tests may show predisposing factors for a cardiogenic syncope: abnormal electrolytes levels, heart enzymes or B-type natriuretic peptide [6]. An echocardiography is indicated when mechanical cardiac causes are suspected, whereas an electrocardiogram is useful in all cardiogenic syncope patients. A normal aspect implies good prognosis, but clinical judgment may still dictate the need for Holter monitoring or loop event recording [7]. The standard electrocardiogram may show atrioventricular blocks of various degrees [8], Brugada syndrome, Wolff-Parkinson-White syndrome or acute ischemia. Sinus pauses, sustained and nonsustained ventricular tachycardia episodes may also be substrates for a cardiogenic syncope. A positive tilt table test indicates a vasodepressor mechanism.

• Torsades De Pointes

  It is characterized by prolonged QT interval, abnormal T wave, torsade de points (TdP) on electrocardiogram, with recurrent syncope, convulsion and even sudden death. [unboundmedicine.com]

  de pointes Cardiovascular syncope Structural outflow obstruction Massive MI Aortic stenosis Mitral valve prolapse Atherosclerosis Pulmonary embolism Pulmonary hypertension Hypertrophic cardiomyopathy Severe asymmetric septal hypertrophy Cardiac tamponade [amboss.com]

  de pointe) and, more rarely, supraventricular tachycardia. [ncbi.nlm.nih.gov]

• Right Bundle Branch Block

  Bifascicular block (right bundle branch block and either left anterior or left posterior fascicular block). [patient.info]

  ECG, electrocardiogram; LBBB, left bundle branch block; PHB, posterior hemiblock; RBBB, right bundle branch block; VT, ventricular tachycardia. [revespcardiol.org]

  bundle branch block pattern with ST elevation in V1–3, suggestive of the Brugada syndrome     Bifascicular block* or undetermined intraventricular conduction abnormalities (QRS ≥ 0.12 s)     Mobitz type I second degree atrioventricular block     Sinus [ncbi.nlm.nih.gov]

• Bifascicular Block

  Bifascicular block (right bundle branch block and either left anterior or left posterior fascicular block). [patient.info]

  […] pattern with ST elevation in V1–3, suggestive of the Brugada syndrome     Bifascicular block* or undetermined intraventricular conduction abnormalities (QRS ≥ 0.12 s)     Mobitz type I second degree atrioventricular block     Sinus bradycardia (< 50 [ncbi.nlm.nih.gov]

However, more research is needed to determine the diagnostic value of these methods.6 Treatment of neurocardiogenic syncope Treatment consists of education, manoeuvres to avert syncope, drug treatment, and pacemakers. [ncbi.nlm.nih.gov]

Despite the significant advances in the treatment of cardiovascular diseases over the past decades, cardiogenic syncope continues to be associated with a significantly worse prognosis when compared with non-cardiogenic syncope. [ncbi.nlm.nih.gov]

Keywords Syncope Prognosis Cardiogenic syncope Emergency department This is a preview of subscription content, log in to check access. Notes Conflict of interest None. References 1. [link.springer.com]

A normal aspect implies good prognosis, but clinical judgment may still dictate the need for Holter monitoring or loop event recording. [symptoma.com]

[…] also known as vasovagal syncope), which is the most common cause of syncope in both children and adults, accounting for 50-66% of unexplained syncope.1 2 The distinction between neurocardiogenic syncope and other causes of fainting is essential, as the prognosis [bmj.com]

Syncope Summary Etiology Clinical features Diagnostics Differential diagnoses Treatment Complications [amboss.com]

[…] consciousness, either with momentary premonitory symptoms or without warning, due to cerebral anemia caused by ventricular asystole, extreme bradycardia, or ventricular fibrillation. neurocardiogenic syncope a particularly serious type of vasovagal attack ; the etiology [medical-dictionary.thefreedictionary.com]

Objectives List the cardiac etiologies of syncope. Differentiate between the various cardiac etiologies of syncope. Discuss the treatment of syncope of cardiac etiology. [emsworld.com]

The reality is that the majority of syncopal episodes have a cardiovascular etiology. The most prominent cause is due to structural or ischemic heart disease leading to bradyarrhythmias and tachyarrhythmias. [eplabdigest.com]

Directly after the event, important clues to the etiology, such as seizure activity, incontinence and immediate vital signs (including body temperature), should be sought. [aafp.org]

Embryology (33) Neurosurgery (30) Infectology (27) Otorhinolaryngology (26) Emergency Medicine (20) Rheumatology (20) Obstetrics, Gynaecology (19) Endocrinology, Metabolism (18) Occupational Medicine and Toxicology (18) Microbiology (16) Haematology (13) Epidemiology [portal.mefanet.cz]

Epidemiologic features of isolated syncope: the Framingham Study. Stroke. 1985; 16 626-629 2 Ganzeboom K S. et al. Prevalence and triggers of syncope in medical students. Am J Cardiol. 2003; 91 1006-1008, A8 3 Blanc J J. et al. [thieme-connect.com]

Epidemiology and prognostic implications of syncope in young competing athletes. Eur Heart J 2004;25:1749-53. [acc.org]

Definition and Epidemiology Syncope is the sudden loss of consciousness, associated with inability to maintain postural tone, with immediate and spontaneous recovery without requiring electrical or chemical cardioversion. [frontiersin.org]

[…] noninvasive risk stratification techniques for identifying patients at risk for sudden cardiac death: a scientific statement from the American Heart Association Council on Clinical Cardiology Committee on Electrocardiography and Arrhythmias and Council on Epidemiology [link.springer.com]

Conclusions We have observed a novel finding of right insular atrophy in patients with NCS with a positive response to HUT, implicating a role of right insular dysfunction in the pathophysiologic mechanism underlying NCS. [ajnr.org]

A review of pathophysiology and therapy of patients with vasovagal syncope. Pharmacotherapy 2000;20: 158-65. [PubMed] [Google Scholar] 4. [ncbi.nlm.nih.gov]

Prevention of Syncope Trial (POST): a randomized, placebo-controlled study of metoprolol in the prevention of vasovagal syncope. Circulation. 2006;113(9):1164–1170. [innovationsincrm.com]

Prevention of Syncope Trial (POST): a randomized, placebo-controlled study of metoprolol in the prevention of vasovagal syncope. Circulation. 2006;113:1164-1170. 26. Di Girolamo E, Di Iorio C, Sabatini P, et al. [uspharmacist.com]

Prevention While most cases of neurocardiogenic syncope cannot be prevented, you can take some steps to reduce your chances – as mentioned above – or spot the signs and reduce your chance of injury during an episode. [baptisthealth.com]

Circulation 2009; 119: 1703-1710 Hypertrophic CardiomyopathyImplantable Defibrillators for Prevention of SDTherapeutic ICD Interventions Regarding Presentation No Sync. or CA Cardiac Arrest Sync.or CA Syncope Begley DA. [slideserve.com]

I do a lot on the prevention side. If I start to feel sick, I sit wherever I can to avoid falling...salt intake water etc etc...it just doesn't seem to control the heart rate from doing it's thing though.... Thank you so much for the link! [medhelp.org]

1. Walsh K, Hoffmayer K, Hamdan MH. Syncope: diagnosis and management. Curr Probl Cardiol. 2015;40 (2):51-86
2. Huff JS, Decker WW, Quinn JV, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with syncope. Ann Emerg Med. 2007;49(4):431-44.
3. Atkins D, Hanusa B, Sefcik T, et al. Syncope and orthostatic hypotension. Am J Med. 1991;91(2):179-85.
4. Calkins H, Shyr Y, Frumin H, et al. The value of the clinical history in the differentiation of syncope due to ventricular tachycardia, atrioventricular block, and neurocardiogenic syncope. Am J Med. 1995;98(4):365-73.
5. Bergfeldt L. Differential diagnosis of cardiogenic syncope and seizure disorders. Heart 2003;89(3): 353-8.
6. Reed MJ, Newby DE, Coull AJ, et al. The ROSE (risk stratification of syncope in the emergency department) study. J Am Coll Cardiol. 2010;23. 55(8):713-21.
7. Rockx MA, Hoch JS, Klein GJ, et al. Is ambulatory monitoring for "community-acquired" syncope economically attractive? A cost-effectiveness analysis of a randomized trial of external loop recorders versus Holter monitoring. Am Heart J. 2005;150(5):1065.
8. Dovgalyuk J, Holstege C, Mattu A, et al. The electrocardiogram in the patient with syncope. Am J Emerg Med. 2007;25(6):688-701.