Syncope natural history, complications and prognosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2]

Overview

Patients with syncope are at risk of the development of complications, such as trauma from frequent falls and Sudden cardiac death. The prognosis of syncope depends on underlying causes. Syncope caused by cardiovascular diseases may be life-threatening and is an important cause of sudden cardiac death. Prognosis of vasovagal syncope is favorable.

Natural history, Complications and Prognosis

Natural History

If underlying cause of syncope left untreated and syncope occurs frequently, patients with syncope may suffer from trauma of the head and neck and sudden cardiac death due to fatal cardiac arrhythmia.

• Clinical characteristic of uncommon causes of syncope include the following:

Uncommon conditions associated with syncope	Clinical aspect	Cause of syncope
Cardiac tamponade	Hypotension, tachycardia, cardiogenic shock	Tachycardia, hypotension, abrupt bradycardia
Constrictive pericarditis	Heart failure symptoms, exertional dyspnea, orthopnea, edema	Cough syncope
Left ventricular non compaction	Trabeculation or recess in left ventricle	Tachyarrhythmia
Takotsubo cardiomyopathy	Apical ballooning , basal hyperkinesia , following stressful event, chest pain and ECG change mimicking ischemia	Uncommon cause of syncope, multifactorial
Pulmonary embolus	Cardiac arrest and pulseless electrical activity following hypoxia, tachycardia, hypotension and shock	Bradycardia, hypotension
Pulmonary arterial hypertension	Exertional syncope, specially in younger patients	Peripheral vasodilation following exercise, low cardiac output state
Amyloidosis	Amyloid deposition in heat, kidney, peripheral and autonomic nervous system	AV block, arrhythmia, low cardiac output due to restrictive cardiomyopathy
Hemochromatosis	Dilated cardiomyopathy due to Iron deposition	Myocardial involvement, sick sinuse syndrome, AV block
Myocarditis	Chest pain, arrhythmia, left ventricular systolic dysfunction, hemodynamic collapse	Ventricular tachycardia, AV block, transient hemodynamic collapse
Lyme disease	Myocarditis accompanied by erythma migrant, neurologic involvement	AV block, vasovagal syncope
disease	Cardiomyopathy caused by trypanosomiasis	Ventricular tachycardia, AV block
Friedreich ataxia	Hypertrophic Cardiomyopathy (HCM), gait ataxia, bladder dysfunction	Tachycardia, bradycardia, SCD is common
Cardiac tumors	Triad of valve obstruction , emboli, systemic signs and symptoms	Obstruction to blood flow
Prosthetic valve thrombosis	Asymptomatic or symptomatic heart failure	Embolic event, valve obstruction
Anomalous coronary artery	Common cause of exertional syncope and SCD specially in young athletes	Bezold jarisch reflex,hypotension, VT, AV block
Subclavian steal syndrome	Significant stenosis in subclavian artery leading flow reversal in vertebral artery and vertebrobasilar ischemia and syncope	Syncope following upper extremities activity
Aortic dissection	Neurologic symptoms, heart failure symptoms, myocardial infarction	Increased risk of inhospital death, tamponade, neurologic deficit in patients with syncope
Coarctation of the aorta (COA)	Heart failure symptoms, dissection of aorta	Associated with bicuspid aortic valve stenosis
Rheumatoid arthritis	Systemic inflammatory disorder	Complete heart block
Carcinoid syndrome, Pheochromocytoma, Mastocytosis,  Vasoactive intestinal peptide tumor	Vasodilation, flushing, pruritus, gastrointestinal symptoms	Transient hypotension
Beta thalassemia major	Dilated cardiomyopathy , severe anemia, multiple organ failure	Arrhythmia
Migraine	Association between headache and syncope	Vasovagal syncope, orthostase intolerance
Seizure-induced bradycardia, hypotension	Temporal lobe epilepsy	Postictal bradyarrhythmia due to temporal lobe or limbic system

Complications

Patients with syncope are at risk of the development of the following complications:

• Frequent falls resulting in injuries to head and neck
• Development of cardiovascular disorders
• Sudden cardiac death
• Death

Prognosis

The prognosis of syncope depends on underlying causes.

• Syncope caused by cardiovascular diseases may be life-threatening and is an important cause of sudden cardiac death.
• Prognosis of vasovagal syncope is favorable.