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ОРИГИНАЛЬНЫЕ СТАТЬИ
КЛИНИЧЕСКОЕ ТЕЧЕНИЕ СИНКОПЕ В ДИФФЕРЕНЦИАЛЬНОЙ ДИАГНОСТИКЕ СИНКОПАЛЬНЫХ СОСТОЯНИЙ
1 2 3 4 2
Piotr J. Stryjewski , Agnieszka Kuczaj , Ryszard Braczkowski , Jadwiga Nessler , Ewa Nowalany-Kozielska
Цель. Оценить клинические признаки и симптомы в дифференциальной диагностике синкопальных состояний.
Материал и методы. Мы исследовали 160 пациентов (64 мужчин и 96 женщин), в возрасте 18-77 лет с рефлекторными и кардиогенными синкопе с продолжительностью более 3 лет. Были исследованы следующие показатели: возраст, пол, возраст появления первого синкопе, количество пресинкопаль-ных эпизодов, число эпизодов, число синкопе без продромальных признаков и обстоятельства обмороков. Кроме того, мы оценили частоту продромальных признаков в дифференциальной диагностике синкопальных состояний. Результаты. Больные с рефлекторными синкопе были моложе по сравнению с больными с кардиогенными синкопе (41,3±16,5 против 61,8±12,8; р<0,001) и имели более низкий вес и индекс массы тела (ИМТ). Больные с рефлекторными синкопе чаще проявляли пресинкопальные признаки (10 (2, 20) против 2 (1, 3); р=0,01)) и их число было больше (8,1±7,8 против 5,4±1,6; р<0,001). Одышка, учащенное сердцебиение, ощущение холода или жара, расстройство зрения и шум в ушах были связаны с рефлекторными обмороками (р<0,01). Заключение. Изучение синкопального состояния может облегчить диагностический процесс рефлекторных и кардиогенных обмороков.
Российский кардиологический журнал 2015, 9 (125): 55-58
http://dx.doi.org/10.15829/1560-4071-2015-09-55-58
Ключевые слова: кардиогенные синкопе, продромальные симптомы, рефлекторные синкопе,синкопальные состояния.
1Cardiology Department, Chrzanow City Hospital; 22nd Department of Cardiology, Zabrze, Medical University of Silesia, Katowice; 3Department of Public Health, Medical University of Silesia, Katowice; 4Coronary Disease Department, Institute of Cardiology, Medical School of Jagiellonian University, John Paul II Hospital, Краков, Польша.
Piotr J. Stryjewski* — MD, PhD, Agnieszka Kuczaj — MD, PhD, Ryszard Braczkowski — MD, PhD, Jadwiga Nessler — MD, PhD, Ewa Nowalany-Kozielska — MD, PhD.
*Автор, ответственный за переписку (Corresponding author): pstryjewski@o2.pl
Рукопись получена 04.05.2015 Рецензия получена 12.05.2015 Принята к публикации 19.05.2015
THE CLINICAL COURSE OF PRESYNCOPE IN THE DIFFERENTIAL DIAGNOSIS OF SYNCOPE
1 2 3 4 2
Piotr J. Stryjewski , Agnieszka Kuczaj , Ryszard Braczkowski , Jadwiga Nessler , Ewa Nowalany-Kozielska
Aim. To evaluate the clinical signs and symptoms in the differential diagnosis of syncope.
Material and methods. We investigated 160 patients (64 men and 96 women), aged 18-77 years with reflex or cardiac syncope over the last 3 years. The following were investigated: age, sex, age at first syncope, number of presyncopal episodes, number of syncopal episodes, number of sudden syncope without prodromal signs and the circumstances of syncope. Moreover, we assessed the frequencies of prodromal signs in the differential diagnosis of syncope.
Results. Patients with reflex syncope were younger compared to patients with cardiac syncope (41,3±16,5 vs. 61,8±12,8; P<0,001) and had lower weight and body mass index (BMI). Reflex syncope patients more often presented with presyncope (10 (2, 20) vs. 2 (1, 3); p=0,01)) and syncope (8,1±7,8 vs. 5,4±1,6; P<0,001). Dyspnea, heart palpitations, feeling of cold or heat, visual disturbances and tinnitus were associated with reflex syncope (P<0,01).
Conclusion. The course of syncope may facilitate a diagnostic process of reflex and cardiac syncope.
Russ J Cardiol 2015, 9 (125): 55-58
http://dx.doi.org/10.15829/1560-4071-2015-09-55-58
Key words: cardiac syncope, prodromal symptoms, reflex syncope, syncope.
Cardiology Department, Chrzanow City Hospital; 22nd Department of Cardiology, Zabrze, Medical University of Silesia, Katowice; 3Department of Public Health, Medical University of Silesia, Katowice; 4Coronary Disease Department, Institute of Cardiology, Medical School of Jagiellonian University, John Paul II Hospital, Cracow, Poland.
Syncope is a transient loss of consciousness caused by transient, general cerebral hypoperfusion, characterized by rapid onset, short duration and spontaneous recovery [1, 2].
The most frequent type of syncope is reflex syncope (neurally-mediated syncope), among which vasovagal syncope is the most frequent type [3].
Vasovagal syncope, which constitutes up to 40% of syncope of unclear origin, is defined as a rapid loss of consciousness due to excessive reaction of the autonomic nervous system [1, 4].
During syncope a rapid decrease in systolic blood pressure occurs and, in consequence, a significant decrease in cerebral blood flow is noted [1, 5].
Cardiac syncope constitutes the second most prevalent type of syncope. The main reasons of cardiogenic syncope are rhythm disturbances such as supraventricular and ventricular tachycardia and bradyarrhytmia (as a combination of sinus node dysfunction, atrioventricular node dysfunction and malfunction of implantable devices). They lead to hemodynamic instability, which may cause a critical decrease in cardiac output and in cerebral blood flow [1, 2].
Determining the cause of syncope is a significant part of syncope evaluation. In the current ESC guidelines for the diagnosis and management of syncope two aspects of patients with syncope were stressed. These are the determination of the exact cause of syncope in order to imple-
Table 1
General characteristics of the studied groups
Parameter Total number of patients n=160 n (%), X±SD Group I — reflex syncope n=80 n (%) Group I — cardiac syncope n=80n (%) P-value
Age, years 50,6±17,3 41,2±15,7 62,1±13,1 0,001
Female gender 96 (60) 51 (63,8) 45 (56,3) NS
Male gender 64 (40) 29 (36,3) 35 (43,8) NS
Height, cm 168,2±9,1 167,1±8,7 169,0±7,9 NS
Weight, kg 74,2±13,9 71,2±14,1 79,1±14,0 0,01
Cardiovascular drugs 74 (46,3) 24 (30) 50 (62,5) 0,001
Annotations: n — number of patients, Data are reported as the mean value ± SD or number (%) of patients. Abbreviations: SD — standard deviation, NS — non significant.
ment the causal treatment and individual patient risk stratification, due to the fact that patient risk is not related to syncope mechanism itself but it is frequently associated with the primary disease [1, 2].
Obtaining history plays a crucial role in establishing the exact cause of syncope. Special consideration should be given to prodromal signs such as dizziness, nausea, weakness, sweating and vision disturbances [1, 6].
The aim of the study was to assess the usefulness of the basic data obtained from patient history and prodromal signs in the differential diagnosis of reflex and cardiac syncope.
Material and methods
We enrolled 160 patients (96 women, 64 men) with a history of syncope, aged 18-77 years, mean age 50,6±17,3 hospitalized in the Coronary Disease Department, the Institute of Cardiology, Medical School of Jagiellonian University, John Paul II Hospital, Cracow, Poland. Reflex or cardiac syncope had been diagnosed in all patients on the basis of investigations, according to the current ESC guidelines [1, 2]. All patients were divided into two groups: group I with reflex syncope and group II with cardiac syncope. A neurological cause of loss of consciousness had been excluded in all patients before enrollment.
The exclusion criteria were as follows: heart failure, decreased left ventricle ejection fraction, unstable coronary artery disease, aortic stenosis, pulmonary embolism.
All patients were diagnosed according to the ESC guidelines [1, 2]. The detailed clinical history was taken with consideration given to:
— the age at first syncope,
— the total number of presyncopal episodes,
— the total number of syncopal episodes,
— the number of syncope without prodromal signs,
— the circumstances immediately prior to the attack (supine, sitting or standing position, activity, crowded or warm place),
— prodromal signs (generalized weakness, dyspnea, palpitations, cold sweats, feeling of cold or heat, blurred vision, tinnitus, headache, abdominal pain, nausea).
Statistical analysis was performed using Statistica 8.1 Statsoft. Numerical continuous variables were presented
Table 2
The detailed cause of syncope in the studied groups
Cause of syncope
Cardiac syncope n=80n (%)
Arrhythmia 76 (95)
Tachycardia
— Supraventricular 35 (43,8)
— Ventricular 24 (30)
Bradycardia
— Sinus node dysfunction 8 (10)
— Atrioventricular conduction system disease 5 (6,3)
Structural disease 4 (5)
— Hypertrophic cardiomyopathy 4 (5)
Reflex syncope n=80n (%)
Typical vasovagal 73 (91,3)
Carotid sinus 3 (3,8)
Situational 4 (5)
Annotations: n — number of patients, Data are reported as the mean value ± SD or number (%) of patients.
Abbreviations: SD — standard deviation, NS — non significant.
as mean values ± standard deviation (SD), dichotomous variables were presented as the percentage. The analysis of normality was performed using the Kolmogorov-Smirnov test, the Lilliefors test and the Shapiro-Wilk test.
The homogeneity of variances was checked using the Levene test and the Brown- Forsyth test. The comparison of the variables with normal distribution was performed using the Student t test for unbound variables.
Nonparametric rank tests (Kolmogorov-Smirnov for two groups and Mann-Whitney U test) were used in the case of variables with non-normal distribution. P values below 0.05 were considered statistically significant.
Results
General characteristics of the study groups were presented in table 1.
Group II (with a cardiogenic cause of syncope) was characterized by older age and more frequently occurring concomitant diseases.
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Table 3
Important features concerning syncope. Cardiac versus reflex syncope
Parameter Reflex syncope n=80 Cardiac syncope n=80 P-value
Age at first syncope, years 22,6±14,8 48,0±8,6 0,001
Number of presyncopal episodes 16,8±21,3 3,2±4,4 0,001
Number of syncopal episodes 8,1±7,8 5,4±1,6 0,001
Suspected heart disease after initial evaluation 16 (26,6) 77 (96,5) 0,001
Syncope in a warm place 8 (10) 2 (2,5) 0,01
Syncope in a crowded place 8 (10) 3 (3,8) 0,02
Syncope in a standing position 60 (75) 48 (60) NS
Syncope in a sitting position 35 (43,8) 23 (28,8) NS
Syncope in a supine position 4 (5) 9 (11,3) NS
Syncope during walking 25 (31,3) 16 (20) NS
Annotations: n — number of patients, Data are reported as the mean value ± SD or number (%) of patients. Abbreviations: SD — standard deviation, NS — non significant.
Table 4
The comparison of the frequency of the occurrence of prodromal symptoms in reflex and cardiac syncope patients
Prodromal symptoms Reflex syncope n=80 n (%) Cardiac syncope n=80 n (%) P-value
General weakness 56 (70) 45 (56,3) NS
Dyspnea 38 (47,5) 18 (22,5) 0,01
Heart palpitations 48 (60) 6 (7,5) 0,0001
Cold sweats 32(40) 25 (31,3) NS
Feeling of cold 34 (42,5) 9(11,3) 0,0001
Feeling of heat 50 (62,5) 25 (31,3) 0,001
Visual disturbances 45 (56,3) 30 (37,5) 0,01
Tinnitus 35 (43,7) 19 (23,8) 0,01
Headache 30 (37,5) 19 (23,8) NS
Stomachache 13 (16,3) 7(8,8) NS
Nausea 29 (36,3) 16 (20) NS
Annotations: n — number of patients, Data are reported as the mean value ± SD or number (%) of patients. Abbreviations: SD — standard deviation, NS — non significant.
Patients with a reflex type of syncope were younger compared to patients with cardiogenic syncope (41,3±16,5 vs. 61,8±12,8; p<0,001), which was previously reported [7].
The syncope mechanism, depending on the studied group is presented in table 2.
The detailed analysis of patient history related to syncope
Analyzing patient history it was established that the age of first syncopal episode was significantly lower in group I compared to group II.
In group I presyncopal and syncopal episodes as well as syncope without prodromal signs were observed more frequently.
Considering the circumstances in which syncope occurred reflex syncope was more prevalent in warm or crowded places.
Data are presented in table 3.
The comparison of the frequency of the occurrence of prodromal symptoms in reflex and cardiac syncope in the studied groups
The mean number of syncope without prodromal signs in group I was 4,7±1,3, whereas in patients from group II was 3,4±1,6 (statistically insignificant difference).
The conducted analysis revealed that dyspnea, heart palpitations, feeling of cold or heat, visual disturbances and tinnitus were significantly more prevalent in patients with reflex syncope (p<0,01). These data are presented in table 4.
Discussion
The first stage of syncope examination according to the current ESC guidelines [1] is the preliminary assessment consisting of detailed clinical history, among other things.
Properly taken clinical history guides further diagnostic process. Clinical history should particularly include questions regarding the occurrence and the duration of prodromal signs, the circumstances of a syncopal episode, the number and the duration of syncopal episodes and potential symptoms occurring after regaining consciousness [8, 9].
Some parameters, potentially significant in the differential diagnosis were observed comparing history of reflex syncope patients to history of cardiac syncope patients.
The main and essential parameter differentiating the two groups of patients is the suspicion of cardiac disease,
which allows predicting cardiac syncope with high sensitivity and specificity. Similarly, the absence of cardiac disease suspicion enables the prediction of reflex syncope with high sensitivity and specificity.
In the presented study we confirmed that patients with reflex syncope are significantly younger compared to patients with a cardiac cause of syncope (41,2±15,7 vs. 62,1±13,1).
On the basis of the epidemiological data about 40% of young people suffered from at least one episode of syncope before the age of 30. About 60-70% of the above-mentioned cases are related to reflex syncope which does not influence life expectancy [10].
However, recurrent reflex syncope in particular can adversely affect the quality of life. Older age is a significant prognostic factor due to the fact that cardiac syncope is connected with a significantly higher risk of death, including sudden cardiac death [11].
Based on other studies, the reason for a higher mortality in the group of older patients is not syncope itself. In fact, the reason is the presence of primary disease [12].
On the other hand, prognosis in young patients with excluded functional or structural heart disease is very good [13, 14].
In the present study, the data obtained from clinical history such as young age at first syncope, a large number of presyncopal episodes and syncopes differ significantly
References
1. Moya A, Sutton R, Ammirati F, et al. Guidelines for the diagnosis and management of syncope (version 2009). The Task Force for th e Diagnosis and Management of Syncope of the European Society of Cardiology (ESC). Eur Heart J. 2009; 30:2631-71.
2. Sutton R, Benditt D, Brignole M, et al. Syncope: diagnosis and management according to the 2009 guidelines of the European Society of Cardiology. Pol Arch Med Wewn. 2010;120: 42-7.
3. Colman N, Nahm K, Ganzeboom KS, et al. Epidemiology of reflex syncope. Clinical Autonomic Research. 2004;14(1):i9-i17.
4. Mosqueda-Garcia R, Furlan R, Tank J, et al. The elusive pathophysiology of neurally mediated syncope. Circulation. 2000; 102(23): 2898-906.
5. Jardine DL. Vasovagal syncope: New physiologic insights. Cardiol Clin. 2013;31(1):75-87.
6. Wieling W, Thijs RD, Van Dijk N, et al. Symptoms and signs of syncope: a review of the link between physiology and clinical clues. Brain. 2009;132(10):2630-42
7. Stryjewski PJ, Nessler B, Kuczaj A, et al. The role of NT-proBNP in the diagnostics and differentiation of cardiac and reflex syncope in adults. Relative importance to clinical presentation and medical examinations. J Interv Card Electrophysiol 2014:41(1):1-8.
between the investigated groups and suggest a reflex type of syncope.
Similarly, the circumstances of syncope such as warm and crowded places are more often related to reflex etiology of syncope.
Prodromal signs such as dyspnea, palpitations, cold sweats, feeling of cold or warm, blurred vision and tinnitus suggest reflex etiology.
The remaining analyzed prodromal signs show no differences regarding the occurrence between the two investigated groups.
The results of the study demonstrate that appropriate questions, which provide clear and relevant answers, enable preliminary differentiation between reflex syncope and other types of syncope [8].
Conclusion
In conclusion, taking detailed clinical history enables preliminary differentiation between cardiogenic and reflex syncope, which based on the ESC guidelines, is the most important part of syncope evaluation next to individual risk stratification.
The results of the presented study may be helpful in improving the diagnostic process of syncope and simultaneously may be useful in avoiding unnecessary investigations and reducing costs of the diagnostic process in patients with syncope.
8. Alboni P, Brignole M, Menozzi C, et al. Diagnostic value of history in patients with syncope with or without heart disease. J Am Coll Cardiol. 2001;37(7):1921-1928.
9. Sheldon R, Rose S, Connolly S, et al. Diagnostic criteria for vasovagal syncope based on a quantitative history. Eur Heart J. 2006;27(3):344-50.
10. Jamalyan SV, Khachatryan LA. Emerging Risk Stratification in Syncope. Eur J Cardiovasc Med. 2010;1:38-48.
11. Kapoor WN, Karpf M, Wieand S, et al. A prospective evaluation and follow-up of patients with syncope. N Engl J Med. 1983; 309(4):197-204.
12. Oh JH, Hanusa BH, Kapoor WN. Do Symptoms Predict Cardiac Arrhythmias and Mortality in Patients With Syncope? Arch Inter Med. 1999;159:375-80.
13. Sarasin FP, Louis-Simonet M, Carballo D, et al. Prospective evaluation of patients with syncope: a population-based study. Am J Med. 2001;111:177-84.
14. Colivicchi F, Ammirati F, Santini M. Epidemiology and prognostic implications of syncope in young competing athletes. Eur Heart J. 2004;25(19):1749-53.
