1. SYNCOPE: WHAT HAPPENS WHEN YOUR LIGHTS GO OUT ? Syed Raza MD,MRCP (UK),FCCP, Dip.Card (UK)

3. Case Mrs L, 64yo F 66yo F , Mrs K, 59yo F Mrs M, 85yo F ? Seizure ? FA L L ? Orthostasis ? Neurocardiogenic

16. Incidence Rates of Syncope According to Age and Sex Soteriades, E. et al. N Engl J Med 2002;347:878-885

18. Classification Syncope Neurally Mediated 34% Vasovagal Carotid Sinus Situational Glossopharyngeal Neuralgia Cerebrovascular Autonomic Failure Cardiac Mediated 18% Arrythmia Srtructural Heart Disease Cardiopulmonary Disease Others 47% Orthostatic Hypotension Idiopathic Medications Psychiatric

25. Carotid Sinus Syncope and Autonomic Dysfunction Freeman, M. Neurogenic Orthostatic Hypotension. NEJM 2008; 358: 616

27. POSTURAL BP

37. TILT TABLE TEST

38. Tilt Table Test In Action

42. Normal test

43. Cardioinhibitory response

44. Vasodepressor response BP drops from 150/70 to 50/30 but heart rate stays same

45. Mixed response BP drops from 150/60 to 50/20 while HR drops from 65 to 30bpm

47. Orthostatic hypotension steady drop in BP and rise in HR

48. Heart Monitoring Options Syncope Occurs Infrequently, Long-term Monitoring is Likely to be Most Effective ILR MCOT External Loop Recorder Typical Event Recorder Holter Monitor 12-Lead 2 Days 7 Days 30+ Days 36 Months 10 Seconds ILR = insertable loop recorder MCOT= mobile cardiac outpatient telemetry

50. Everything is spinning

54. Management of Neurally Mediated Syncope Grubb BP. NEJM. 2005. 352(10): 1004-1010

58. Soteriades E et al. N Engl J Med 2002;347:878-885 Overall Survival of Participants with Syncope, According to Cause, and Participants without Syncope

59. Driving Implications Group 1 Entitlement Group 2 Entitlement Simple faint –definite provocation with prodromal symptoms No driving restrictions No driving restrictions Unexplained syncope with low risk of recurrence Can drive 4 weeks after the event Can drive 3 months after the event Unexplained syncope & high risk of recurrence A abnormal ECG B structural heart disease C syncope at the wheel or results in injury D more than 1 episode in last 6 months Can drive 4 weeks after the event if cause identified and treated If no cause – 6 months off Can drive after 3 months if the cause identified and treated If no cause, licence revoked for year Loss of consciousness with no clinical pointers Full neuro/cardiac Ix with no pointers Licence revoked for 6 months Licence revoked for 1 year Cough syncope Stop driving until symptoms controlled Stop driving If smokes or respiratory disease have to be controlled for 5 years

62. ANY QUESTION ??