Today we discussed a case of syncope. Syncope itself has a broad differential but an important differentiation is the divide between cardiac and non-cardiac causes of syncope. We discussed that when a person has a very sudden loss of consciousness (no prodrome) and very rapid recovery we are concerned that the underlying etiology is of the ‘cardiac’ variety. As astute clinician seeing a patient after a syncopal episode will notice injuries such as bruising of the head and face to suggest that someone has fainted suddenly without enough warning to brace their fall.Differential Diagnosis of Syncope:
Neurally medicated: constitutes approximately 20-25% of cases. This category includes vasovagal attacks, situational syncope and carotid sinus syncope. Of this group, vasovagal syncope is by far the most common. Consider vasovagal syncope in people when the event is preceded by pain, fear, extreme emotional stress, micturition or when someone has been standing for long periods of time.
Cardiac disease (up to 20%): includes abnormality any part of the heart i.e. pericardium, myocardium and valves. In addition to organic heart disease consider also arrhythmias. Finally a rare cause that was discussed today - the atrial myxoma – could be considered in particular in those people who have positional syncope such us when bending down.
Orthostatic hypotension: Should be identified on physical exam by postural vitals. This category included volume depletion, medication medicated orthostasis, autonomic dysfunction etc.
Neurologic Disorders: vertebrobasilar ischemia
Unknown: up to 1/3 of syncope used to be considered to have no obvious etiology however with improved diagnostics e.g. tilt table testing for neurally mediated mechanisms this number is likely lower now.
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