1/3. A patient with recurrent syncope and ST-elevation on the electrocardiogram.A 56-year old woman had over 100 episodes of syncope since the age of 8. Because the patient's description of the episodes suggested vasovagal syncope she was studied by a head up tilt test (HUT). Seconds after the uncomplicated HUT the patient experienced a typical syncope with bradycardia, marked ST-elevation and chest pain. After treatment with nifedipine she has had one syncopal spell in a follow up period of 31 months. We conclude that the syncopal events in this patient were caused by a combination of vasovagal syncope and coronary spasm.- - - - - - - - - - ranking = 1keywords = chest (Clic here for more details about this article) |
2/3. syncope: case studies.In this series of clinical vignettes, the authors have attempted to provide a "feel" for the varied causes of syncope. The neurologist should be able to diagnose most causes of syncope using a simple algorithmic approach. Initial evaluation includes detailed clinical history, physical examination, and 12-lead ECG. Following initial evaluation, the cause of syncope is usually immediately apparent (typical story for vasovagal syncope, clinically demonstrable autonomic failure, long QT), strongly suspected (syncope preceded by chest pain or palpitations), or uncertain. In the latter group of patients, further workup will depend on the suspicion or documented presence of heart disease. In those with a single episode of syncope and no evidence of heart disease, further workup may not be necessary. In patients over 60 years of age with recurrent episodes and no cardiac history or abnormal ECG, tilt-table testing and carotid sinus massage may be diagnostic. If no diagnosis is found, an implantable loop monitor may be needed. patients with heart disease will need the most comprehensive evaluations, possibly including exercise testing, cardiac electrophysiology, and tilt-table testing. As better understanding of pathophysiology and epidemiology emerge, under-standing of the diagnosis and treatment of syncope will improve. In the meantime, there is no substitute for astute clinical acumen.- - - - - - - - - - ranking = 1keywords = chest (Clic here for more details about this article) |
3/3. Vasodepressor syncope due to subclinical myocardial ischemia.INTRODUCTION: Vasodepressor syncope is a common cause of syncope, but the initiating event that triggers the vasodepressor response remains incompletely understood. Although ischemia due to acute right coronary occlusion may precipitate hypotension and bradycardia through the Bezold-Jarisch reflex, an ischemic precipitant for the common vasodepressor faint has not been previously identified. In the present study, we present evidence for a causal relationship between myocardial ischemia and vasodepressor syncope. methods AND RESULTS: Two patients referred for evaluation of syncope underwent upright tilt table testing with either ST segment monitoring, sestamibi scintigraphy and echocardiography during the tilt test, or coronary angiography. Both patients had positive tilt table tests during the control study. Patient 1 was documented to have reproducible ischemic ECG changes during atypical chest pressure induced by upright tilt, despite a normal coronary angiogram with ergonovine provocation. Subsequent tilt testing with simultaneous sestamibi perfusion imaging and echocardiography revealed reversible anterolateral hypoperfusion corresponding with anterolateral hypokinesis during upright tilt that preceded syncope. Ischemic ECG changes during incremental rapid atrial pacing further suggested ischemia on the basis of microvascular disease. Follow-up tilt testing on verapamil was negative. Patient 2 developed ischemic ECG changes during the recovery phase of an exercise stress test, which was followed by a vasodepressor response and frank syncope. coronary angiography revealed a 90% distal right coronary artery stenosis that was successfully dilated, after which follow-up tilt table testing off all other medication was negative. CONCLUSIONS: These two cases illustrate a previously unrecognized causality between myocardial ischemia and clinical vasodepressor syncope, and demonstrate that subtle manifestations of myocardial ischemia, associated with either atypical angina or silent ischemia, can provoke syncope.- - - - - - - - - - ranking = 1keywords = chest (Clic here for more details about this article) |