Today, I review, link to, and excerpt from StatPearls‘ Cardiac Syncope. Esther M. Mizrachi1; Kranthi K. Sitammagari2. Last Update: April 10, 2023.
All that follows is from the above resource.
Introduction
Syncope, a sudden, transient loss of consciousness and postural tone, is a phenomenon estimated to affect 30% to 40% of the population, and those numbers are likely underestimated given the high prevalence of patients with syncope who do not present to a hospital or urgent care setting. Syncope is responsible for 740,000 trips to the emergency department and a quarter of a million hospital admissions each year in the United States alone.[1] Causes of syncope range widely, including vasovagal, neurologic, metabolic, pulmonary, volume depletion, and cardiac. While most syncopal events are innocuous, cardiac syncope is often indicative of a potentially fatal, underlying disease process, carrying a one-year mortality rate of 30%.[2] Cardiac syncope occurs when the source of one’s loss of consciousness stems from a problem in the heart that prevents it from supplying enough nutrients and oxygen to the brain. This cardiac problem may be a rhythm disturbance, a structural problem, or a structural problem that predisposes a patient to a rhythm disturbance. Cardiac syncope is estimated to be the cause of syncope in 15% of syncopal events.[3] Distinguishing cardiac syncope from the myriad of other syncopal etiologies can be challenging. For this reason, it is imperative for all healthcare providers to have a general understanding of cardiac syncope and how to recognize it.[4][5]
Etiology
Syncope is caused by a temporary global failure of cerebral perfusion. When cardiac, the brain is not perfused because the heart is failing to generate enough cardiac output to send its freshly oxygenated blood to the brain. This is typically secondary to either a mechanical or structural cardiac defect or an arrhythmia that alters electrical conduction through the myocardium. Arrhythmias are recognized as the more common mechanism of the two. However, structural and mechanical abnormalities in the heart will often induce such arrhythmias. These processes are therefore often interrelated.
The following is a brief list of the more common etiologies of cardiac syncope. Further discussion regarding how to recognize and manage these etiologies will follow.
Structural
Electrical
Tachyarrhythmia
Bradyarrhythmia
Inherited channelopathies
QT interval disorders (Long or short QT)
Brugada syndrome
Catecholaminergic polymorphic ventricular tachycardia
Epidemiology
Syncope is a relatively common phenomenon encountered among patients of every age range, race, religion, and socioeconomic status. Cardiovascular disease is the second most common cause of syncope, with arrhythmias being far more common than structural diseases. Ventricular tachycardia alone is responsible for 11% of syncopal events. Cardiovascular syncope overall is far more prevalent in the elderly population than the younger population, with 10% to 30% of syncopal events in patients over 60 having a cardiac origin. Cardiovascular syncope is also more common in men than in women.[6]
Structural cardiac diseases are more prevalent among patients with comorbidities such as diabetes, hypertension, hyperlipidemia, and patients who smoke. Pre-excitation syndromes tend to be more common among women than men.[7]
Brugada syndrome is more common among males and people of Southeast Asian descent.[3]
Pathophysiology
All cases of cardiac syncope have the same general mechanism. When the heart fails to generate adequate cardiac output, the brain is inadequately perfused and temporarily malfunctions, leading to the syncopal event. Bradyarrhythmias lead to this final pathway because the heart is too slow to generate enough flow. Tachyarrhythmias force the heart to pump so fast that it lacks an adequate diastolic phase, leading to ineffective ventricular filling and reduced cardiac output.
Mechanical obstructions to blood flow and cardiac output will have similar effects but through multiple possible mechanisms. A chronic obstruction to forward blood flow out of the heart will lead to an increase in ventricular size and pressure. The increase in size leads to ventricular myocyte irritability, which can potentially induce arrhythmias. The increase in pressure can stimulate mechanoreceptors and induce a vagal response and secondary hypotension and bradycardia. This is in addition to the primary structural problem of the impeded forward blood flow. Obstructive pathologies, such as aortic stenosis, tumors, tamponade, and congenital hypertrophic cardiomyopathy can all follow this pathway, as can myocardial infarction and ischemia. Infarcted or ischemic ventricular tissue will have impaired contractility. Infarction of valves or chordae tendineae can lead to valve rupture, resulting in subsequent mechanical obstruction to forward flow or induction of retrograde blood flow. When cardiac tissue damage is present along with the conduction system, conduction blocks and other arrhythmias can result. Aortic dissection can induce myocardial infarction when the dissection extends into the coronaries supplying vital portions of the myocardium. A leaking or ruptured aortic dissection can also diminish cardiac output through induction of hypovolemia or tamponade (if aortic contents extend into the pericardium). Pulmonary hypertension and pulmonary emboli will lead to a blockade of flow through the pulmonary artery and a reduction in left-sided preload and subsequent cardiac output in addition to the primary potential symptom of hypoxia.[6]
Histopathology
Hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy are two sources of cardiac syncope that are recognizable by specific histopathologic findings.
Hypertrophic Cardiomyopathy
Hypertrophic cardiomyopathy is a myocardium disease in which a portion of the left ventricle asymmetrically hypertrophies, often in the septum. This leads to diminished left ventricular filling volume and contractility secondary to the stiffened, overgrown myocardium. The diminished left ventricular filling volume obstructs cardiac output, resulting in diminished blood flow to intramural coronary vessels and the rest of the body. The classic findings on myocardial biopsy of patients with hypertrophic cardiomyopathy are a thickened myocardium (often specifically in the septum) with disorganization of the myocyte fibers, myocardial scarring, and fibrosis along with narrowed vessels and dysplasia of the tunica media cells.
Arrhythmogenic Right Ventricular Cardiomyopathy
Arrhythmogenic right ventricular cardiomyopathy can be identified pathologically by fibrous tissue and fat cells replacing myocytes within the right ventricle. Patients with this condition will have dilated right ventricles and sometimes may have ventricular aneurysms. These can be particularly dangerous when located in the posterior basal, apical, or outflow tract portions of the heart.[8]
History and Physical
When evaluating a syncopal patient to assess for a cardiac etiology, clinical history (when available) is one of the most useful diagnostic tools. Clinical history and physical exam alone have been found to identify an accurate diagnosis in 45% of patients who had a primary identifiable etiology of their syncope.[9] Important aspects of the history that will lead to the determination of a cardiac etiology include older age (greater than 60 years), male sex, past medical history significant for any primary cardiac disease, coronary artery disease, valvular disease, or pulmonary emboli/pulmonary emboli risk factors (cancer, immobility, pregnancy, oral contraceptive pill use, etc.). In addition, cardiovascular syncope will more commonly be associated with exertion, occur when supine, involve prodromal palpitations or chest pain, and lack prodromal vagal symptoms. Other key historical clues include a family history of arrhythmias, syncope, or early, unexplained death.[10]
A careful physical exam will assess heart rate and rhythm. Any abnormalities will increase suspicion of cardiac arrhythmia. In addition, an elevated respiratory rate or hypoxia will increase suspicion of a pulmonary embolism. Jugular venous distention and hypotension are suggestive signs of an obstructive mechanical cardiac etiology. Pathological cardiac murmurs, specifically new ones, will clue one into a valvular etiology, hypertrophic cardiomyopathy, or an obstructive intracardiac lesion. Muffled sounds can be heard with pericardial tamponade. Pedal edema or other evidence of deep venous thrombosis increases a patient’s risk of pulmonary embolism.[10]
Evaluation
When a syncopal event is identified as cardiac in origin, further workup should involve a 12 lead EKG, rhythm monitoring, and potential further studies such as an echocardiogram, implantable cardiac monitor, or Holter and/or stress test.
The EKG is a helpful tool for identifying arrhythmias
Basic lab tests, such as a complete blood count and basic metabolic panel, are frequently performed on patients presenting to an emergency department with syncope. However, these tests do not assist in predicting cardiac etiology.[10] Troponin, similarly, performs poorly as a diagnostic tool among syncopal patients. However, when measured among syncopal patients, the natriuretic peptide has demonstrated utility in identifying patients with cardiac syncope and patients at risk of short-term major adverse cardiac events (sensitivity, 73%; specificity, 88%).[11][12]
Once cardiac syncope is suspected, if no arrhythmia is identified, echocardiography is perhaps the most useful follow-up diagnostic test as it will directly identify structural abnormalities, as described above. In a retrospective study of 128 patients suspected of having a cardiac syncope, the echocardiogram confirmed diagnosis in 48% of patients and 77% of patients with a specific cardiac diagnosis.[13] CT and MRI are also useful modalities in identifying structural cardiac pathologies, such as pulmonary emboli, cardiac masses, congenital heart disease, sarcoidosis, and arrhythmogenic right ventricular cardiomyopathy.[14][15]
If cardiac syncope is not secondary to a mechanical problem and no arrhythmia is detected on initial EKG, stress testing and longer-term rhythm monitoring can be effective in catching the diagnosis. In cases of exertional syncope, exercise stress testing will often reveal the diagnosis.[16] When symptoms are recurrent and frequent, a Holter monitor is recommended. If syncopal or pre-syncopal symptoms are recurrent but not frequent enough to be noted on the Holter monitor, an external loop recorder or implanted cardiac monitor can be used to generate a diagnosis.[10]
The electrophysiologic study is another method that has been utilized to identify cases of cardiac syncope. This study involves the placement of catheter tips at multiple locations within the heart. Testing begins at the SA node and progresses throughout the remainder of the heart. During the study, the heart is paced. An electric current is injected into various nonconducting endocardium regions and along the conduction pathway to attempt to reproduce an arrhythmia. Slow and/or fast pacing and proarrhythmic drugs may also be utilized for this purpose. When an arrhythmia occurs, this study allows the electrophysiologist to find the exact source of the irregular electrical activity and allows for any misfiring cells’ ablation. This procedure can thus be both diagnostic and therapeutic. Theoretically, this sounds like an excellent test. However, in practice, this test has poor sensitivity and specificity. It is only recommended in patients with concurrent ischemic heart disease who would not otherwise receive an implanted cardiac defibrillator or other high-risk patients in whom no other tests could reveal a diagnosis. Electrophysiologic studies are only considered diagnostic if they induce sinus bradycardia with a prolonged sinus node recovery time of more than 525 milliseconds, a bundle branch block with tachycardia or a His-Purkinje block (second or third degree), sustained monomorphic ventricular tachycardia in a patient with preexisting cardiac infarction, or recurrent symptoms in the setting of rapid supraventricular tachycardia.[17]
