Syncope: Difference between revisions

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===Clinic===
===Clinic===
*Here Syncope is an Umbrella which refers to Reflex syncope/ Vasovagal Syncope / Orthostatic hypotension
*It is a brief loss of consciousness due to a neurologically induced drop in blood pressure and/or a decrease in heart rate.
*Before an affected person passes out, there may be sweating, a decreased ability to see, or ringing in the ears.
*Occasionally, the person may twitch while unconscious


* '''Syncope''', commonly known as '''fainting''', or '''passing out'''
* Due to its etiology, syncope has three forms
*# Orthostatic syncope
*# Reflex syncope (Vasovagal Syncope)


=== Orthostatic syncope ===


===Signs / Symptoms===
* It refers to syncope resulting from a postural decrease in blood pressure.
* It occurs when there is a persistent reduction in blood pressure of at least 20mmHg systolic or 10mmHg diastolic within 3 minutes of standing or being upright to 60 degrees on the head-up tilt table.
* In people with initial orthostatic hypotension, the decrease in blood pressure occurs within 15 seconds, while in those with ''delayed'' orthostatic hypotension it occurs after over 3 minutes of assuming an upright position.
 
=== Reflex syncope ===
 
* Reflex syncope is a brief loss of consciousness due to a neurologically induced drop in blood pressure and/or a decrease in heart rate.
* It is divided into three types:
*# Vasovagal which is typically triggered by seeing blood, pain, emotional stress, or prolonged standing.
*# Situational which is often triggered by urination, swallowing, or coughing.
*# Carotid sinus which is due to pressure on the carotid sinus in the neck.
 
 
===[[Sign Symptom Paraclinic|Sign / Symptom]] ===


* Loss of consciousness  
* Loss of consciousness  


*Lightheadedness
*Light-headedness, Nausea
*Nausea
*Feeling of  hot / cold + sweating
*Feeling of  hot / cold + sweating)
*Ringing in the ears
*Ringing in the ears
*Uncomfortable feeling in the heart
*Uncomfortable feeling in heart
*Confusion, a slight inability to speak or form words
*Confusion: Slight inability to speak or form words
*Visual disturbances such as lights seeming too bright, fuzzy or tunnel vision, black cloud-like spots in vision
*Visual disturbances such as lights seeming too bright, fuzzy or tunnel vision, black cloud-like spots in vision
*Nervousness
*Nervousness
===Causes===
*Reflex syncope occurs in response to a trigger due to dysfunction of the heart rate and blood pressure regulating mechanism.
*When heart rate slows or blood pressure drops, the resulting lack of blood to the brain causes fainting.


*Regardless of the trigger, the mechanism of syncope is similar in the various vasovagal syncope syndromes.
=== Mechanism ===
*The nucleus tractus solitarii of the brainstem is activated directly or indirectly by the triggering stimulus, resulting in simultaneous
{| class="wikitable"
**Enhancement of parasympathetic nervous system (vagal) tone
!Orthostatic syncope
**Withdrawal of sympathetic nervous system tone.
!Reflex syncope
This results in a spectrum of hemodynamic responses:
|-
#On one end of the spectrum is the cardioinhibitory response, characterized by a drop in heart rate (negative chronotropic effect) and in contractility (negative inotropic effect) leading to a decrease in cardiac output that is significant enough to result in a loss of consciousness. It is thought that this response results primarily from enhancement in parasympathetic tone.
|
#On the other end of the spectrum is the vasodepressor response, caused by a drop in blood pressure (to as low as 80/20) without much change in heart rate. This phenomenon occurs due to dilation of the blood vessels, probably as a result of withdrawal of sympathetic nervous system tone.
* In upright position, there is an immediate gravitational pooling  blood to the lower extremities, splanchnic and pulmonary circulations. The decrease in venous return to the heart reduces cardiac output and eventually causes a drop in blood pressure.
#The majority of people with vasovagal syncope have a mixed response somewhere between these two ends of the spectrum.
* Carotid and aortic Baroreceptors sense this decrease in blood pressure and activate the sympathetic nervous system which leads to increased heart rate, systemic vasoconstriction, and increased cardiac muscle contractility all of which eventually increase blood pressure.
One account for these physiological responses is the Bezold-Jarisch reflex.
* In Autonomic dysfunction, there is an inadequate engagement of the autonomic nervous system in response to a decrease in blood pressure leading to persistent hypotension.
 
|
Vasovagal syncope may be part of an evolved response, specifically, the fight-or-flight response.
# Enhancement in parasympathetic tone which lends in  
#* Negative chronotropic effect: Bradycardia
#* Negative inotropic effect leading to a decrease in cardiac output and loss of consciousness
# withdrawal of sympathetic nervous system tone, which leads in vasodepressor response and a drop in blood pressure without much change in heart rate.
# But vasovagal syncope often have a mixed response.
|}


=== Dynamic vs Static [[Sign Symptom Paraclinic|SSPs]] ===


*Syncope has a lot of Symptoms, but most of them are post-nodes.
* It means that Confusion, Dizziness, Blurred vision, Fatigue, Coma and Ext coldness are all caused by Hypotention.
* In another word they are not caused by the miasm dependently, but they are the direct effect of hypotention.
* So I delete all of them. I suggest only Orthostatic Hypotention as fixed [[Sign Symptom Paraclinic|SSP]] and Bradycardia as changeable SSP.
* Also I suggest the rubric


===Types===
=== Entity / Miasm ===
Reflex syncope is divided into three types:
#Vasovagal: Typically triggered by seeing blood, pain, emotional stress, or prolonged standing.
#Situational: Triggered by urination, swallowing, or coughing
#Carotid sinus: Due to pressure on the carotid sinus in the neck


* I can only suggest one rubric, which is G/ Hypotention/ Orthostatic and have 7 miasms: SAHF, HSV-1, CMV, HIV, HTLV-1, LBB, TBE




=== Orthostatic hypotension ===


* Also known as postural hypotension, is a medical condition wherein a person's blood pressure drops when standing up or sitting down.
=== Related diseases ===
* Primary orthostatic hypertension is also often referred to as neurogenic orthostatic hypotension.
* [[Addison's disease]]
* Hypotension may be
* [[Atherosclerosis]]
** Sudden (vasovagal orthostatic hypotension)
* [[Diabetes mellitus|Diabetes]]
** Within 3 minutes (classic orthostatic hypotension)
** Gradual (delayed orthostatic hypotension)
 
* It is defined as a fall in systolic blood pressure of at least 20 mmHg or diastolic blood pressure of at least 10 mmHg after 3 mins of standing. It occurs predominantly by delayed (or absent) constriction of the lower body blood vessels, which is normally required to maintain adequate blood pressure when changing the position to standing. As a result, blood pools in the blood vessels of the legs for a longer period, and less is returned to the heart, thereby leading to a reduced cardiac output and inadequate blood flow to the brain.
 
Very mild occasional orthostatic hypotension is common and can occur briefly in anyone, although it is prevalent in particular among the elderly and those with known low blood pressure. Severe drops in blood pressure can lead to fainting, with a possibility of injury.
 
* Moderate drops in blood pressure can cause confusion/inattention, delirium, and episodes of ataxia.
 
==== Related diseases ====
 
* Addison's disease
* Atherosclerosis
* Diabetes
* Pheochromocytoma
* Pheochromocytoma
* Porphyria
* Porphyria
==== Related neurological disorders ====


* [[Autoimmune autonomic ganglionopathy]]
* [[Autoimmune autonomic ganglionopathy]]
* [[Multiple system atrophy]]
* [[Multiple system atrophy]]
* Other forms of dysautonomia
* [[Ehlers Danlos syndrome|Ehlers–Danlos syndrome]]
* Ehlers–Danlos syndrome
* [[Anorexia nervosa]], [[Bulimia|Bulimia nervosa]]
* Anorexia nervosa
* [[Parkinson disease|Parkinson's disease]]
* [[Parkinson disease|Parkinson's disease]]
* [[Dementia with Lewy bodies|Lewy body dementias]] : Resulting from sympathetic denervation of the heart or as a side effect of dopaminomimetic therapy. This rarely leads to fainting unless the person has developed true autonomic failure or has an unrelated heart problem. Chronic orthostatic hypotension is associated with cerebral hypoperfusion that may accelerate the pathophysiology of dementia.
* [[Dementia with Lewy bodies|Lewy body dementias]]
 
Another disease, dopamine beta hydroxylase deficiency, also thought to be underdiagnosed, causes loss of sympathetic noradrenergic function and is characterized by low or extremely low levels of norepinephrine, but an excess of dopamine.
 
Quadriplegics and paraplegics also might experience these symptoms due to multiple systems' inability to maintain normal blood pressure and blood flow to the upper part of the body.
 
* Patients prone to orthostatic hypotension are the elderly, ''post partum'' mothers, and those having been on bed rest. People with anorexia nervosa and bulimia nervosa often develop orthostatic hypotension as a common side effect. Consuming alcohol may also lead to orthostatic hypotension due to its dehydrating effects


=== Note ===
Cardiogenic Neurological and syncopes usually come together but there is some guides to be differentiated from each other


==== Mechanism ====
Orthostatic hypotension happens when gravity causes blood to pool in the lower extremities, which in turn compromises venous return, resulting in decreased cardiac output and subsequent lowering of arterial pressure. For example, changing from a lying position to standing loses about 700 ml of blood from the thorax, with a decrease in systolic and diastolic blood pressures. The overall effect is insufficient blood perfusion in the upper part of the body.<sup>[''citation needed'']</sup>
Normally, a series of cardiac, vascular, neurologic, muscular, and neurohumoral responses occurs quickly so the blood pressure does not fall very much. One response is a vasoconstriction (baroreceptor reflex), pressing the blood up into the body again. (Often, this mechanism is exaggerated and is why diastolic blood pressure is a bit higher when a person is standing up, compared to a person in the horizontal position.) Therefore, some factor that inhibits one of these responses and causes a greater than normal fall in blood pressure is required. Such factors include low blood volume, diseases, and medications.<sup>[''citation needed'']</sup>
=== My Theory ===
Like other issues, here we have a lot of medical condition such as Orthostatic Hypotention, Fainting, Vasavagal Syncope and Situational syncope with a lot of related disease and underlying mechanisms, which means that we know but cannot classify our knowledge, since we do not pay attention to miasm.
Here I suggest a binary categorization. (1) Cardiogenic AND (2) Neurological Syncope. Here we already have a good defenition, Neurocardiogenic syncope<ref>Chen-Scarabelli C, Scarabelli TM. Neurocardiogenic syncope. BMJ. 2004 Aug 7;329(7461):336-41. doi: 10.1136/bmj.329.7461.336. PMID: 15297344; PMCID: PMC506859.</ref>
*Hypotention of Cardiogenic origin occurred in 2-3 min, but in Neurologic one, Hypotention occurred immediately.
*Hypotention of Cardiogenic origin occurred in 2-3 min, but in Neurologic one, Hypotention occurred immediately.
*Cardiogenic syncope is accompanied by valvular heart diseases, myocardial diseases, and cardiac arrhythmia, while neurologic syncope is accompanied by neurologic disorders.
*Cardiogenic syncope is accompanied by valvular heart diseases, myocardial diseases, and cardiac arrhythmia, while neurologic syncope has neurologic causes.
*Neurologic Syncope is more often in elderly people. <ref>Nwazue VC, Raj SR. Confounders of vasovagal syncope: orthostatic hypotension. Cardiol Clin. 2013 Feb;31(1):89-100. doi: 10.1016/j.ccl.2012.09.003. PMID: 23217690; PMCID: PMC3589989.</ref>
*Neurologic Syncope is more often in elderly people. <ref>Chen-Scarabelli C, Scarabelli TM. Neurocardiogenic syncope. BMJ. 2004 Aug 7;329(7461):336-41. doi: 10.1136/bmj.329.7461.336. PMID: 15297344; PMCID: PMC506859.</ref> <ref>Nwazue VC, Raj SR. Confounders of vasovagal syncope: orthostatic hypotension. Cardiol Clin. 2013 Feb;31(1):89-100. doi: 10.1016/j.ccl.2012.09.003. PMID: 23217690; PMCID: PMC3589989.</ref>
===Entities / Miasms===
{| class="wikitable"
!
!SAHF
![[YF, Yellow Fever|YF]]
![[HFRS, Hemorrhagic Fever with Renal Syndrome|HFRS]]
![[WNE, West Nile Encephalitis|WNE]]
!CXB
ECHO
!HSV-1
!STLE
NPH
!RBS
!TBE
|-
|Hypotention
| +++
| +++
| +++
|
| +++
| +++
|
| +++
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|-
|Orthostatic
Hypotention
| +++
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|
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|
| +++
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|
| +
|-
|Coma
| +++
| +++
|
| +++
| +++
| +++
| +++
| +++
| +++
|-
|Dizziness
| +++
|
| +++
|
|
|
| +++
|
|
|-
|Shock
| +++
| +++
| +++
| +++
| +++
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|-
|Flushed face
| +++
| +++
| +++
| +++
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|
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|-
|Nervous system
| +++
| +++
|
| +++
| +++
|
| +++
| +++
| +++
|-
|Blood
| +++
| +++
| +++
|
|
|
|
|
|
|}
*SAHF is the best for both of them. Intrestingly SAHF has Vasoconstriction which is very Consonant  to circulatory origine
*Obviously HFRS and HSV-1 do not Neurogenic syncope
*HFRS is special for Cardiogenic Syncope
*YF, WNE, CXA-B, ECHO, STLE and RBS are good candidates of Neurogenic Syncope
 
 
=== Dysautonomia ===
 
* I know syncope is not one entity.
* I consider it as a cluster of entities
* I  suggest this cluster for Autonomic dysfunction

Latest revision as of 21:40, 2 October 2023

Clinic

  • Syncope, commonly known as fainting, or passing out
  • Due to its etiology, syncope has three forms
    1. Orthostatic syncope
    2. Reflex syncope (Vasovagal Syncope)

Orthostatic syncope

  • It refers to syncope resulting from a postural decrease in blood pressure.
  • It occurs when there is a persistent reduction in blood pressure of at least 20mmHg systolic or 10mmHg diastolic within 3 minutes of standing or being upright to 60 degrees on the head-up tilt table.
  • In people with initial orthostatic hypotension, the decrease in blood pressure occurs within 15 seconds, while in those with delayed orthostatic hypotension it occurs after over 3 minutes of assuming an upright position.

Reflex syncope

  • Reflex syncope is a brief loss of consciousness due to a neurologically induced drop in blood pressure and/or a decrease in heart rate.
  • It is divided into three types:
    1. Vasovagal which is typically triggered by seeing blood, pain, emotional stress, or prolonged standing.
    2. Situational which is often triggered by urination, swallowing, or coughing.
    3. Carotid sinus which is due to pressure on the carotid sinus in the neck.


Sign / Symptom

  • Loss of consciousness
  • Light-headedness, Nausea
  • Feeling of hot / cold + sweating
  • Ringing in the ears
  • Uncomfortable feeling in heart
  • Confusion: Slight inability to speak or form words
  • Visual disturbances such as lights seeming too bright, fuzzy or tunnel vision, black cloud-like spots in vision
  • Nervousness

Mechanism

Orthostatic syncope Reflex syncope
  • In upright position, there is an immediate gravitational pooling blood to the lower extremities, splanchnic and pulmonary circulations. The decrease in venous return to the heart reduces cardiac output and eventually causes a drop in blood pressure.
  • Carotid and aortic Baroreceptors sense this decrease in blood pressure and activate the sympathetic nervous system which leads to increased heart rate, systemic vasoconstriction, and increased cardiac muscle contractility all of which eventually increase blood pressure.
  • In Autonomic dysfunction, there is an inadequate engagement of the autonomic nervous system in response to a decrease in blood pressure leading to persistent hypotension.
  1. Enhancement in parasympathetic tone which lends in
    • Negative chronotropic effect: Bradycardia
    • Negative inotropic effect leading to a decrease in cardiac output and loss of consciousness
  2. withdrawal of sympathetic nervous system tone, which leads in vasodepressor response and a drop in blood pressure without much change in heart rate.
  3. But vasovagal syncope often have a mixed response.

Dynamic vs Static SSPs

  • Syncope has a lot of Symptoms, but most of them are post-nodes.
  • It means that Confusion, Dizziness, Blurred vision, Fatigue, Coma and Ext coldness are all caused by Hypotention.
  • In another word they are not caused by the miasm dependently, but they are the direct effect of hypotention.
  • So I delete all of them. I suggest only Orthostatic Hypotention as fixed SSP and Bradycardia as changeable SSP.
  • Also I suggest the rubric

Entity / Miasm

  • I can only suggest one rubric, which is G/ Hypotention/ Orthostatic and have 7 miasms: SAHF, HSV-1, CMV, HIV, HTLV-1, LBB, TBE


Related diseases

Note

Cardiogenic Neurological and syncopes usually come together but there is some guides to be differentiated from each other

  • Hypotention of Cardiogenic origin occurred in 2-3 min, but in Neurologic one, Hypotention occurred immediately.
  • Cardiogenic syncope is accompanied by valvular heart diseases, myocardial diseases, and cardiac arrhythmia, while neurologic syncope has neurologic causes.
  • Neurologic Syncope is more often in elderly people. [1] [2]
  1. ↑ Chen-Scarabelli C, Scarabelli TM. Neurocardiogenic syncope. BMJ. 2004 Aug 7;329(7461):336-41. doi: 10.1136/bmj.329.7461.336. PMID: 15297344; PMCID: PMC506859.
  2. ↑ Nwazue VC, Raj SR. Confounders of vasovagal syncope: orthostatic hypotension. Cardiol Clin. 2013 Feb;31(1):89-100. doi: 10.1016/j.ccl.2012.09.003. PMID: 23217690; PMCID: PMC3589989.
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