晕厥的病因和诊断策略.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,1,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,晕厥的病因和诊断策略陈庆华 ppt课件,晕厥的病因和诊断策略陈庆华 ppt课件晕厥的病因和诊断策略陈庆华 ppt课件The Significance of Syncope1 National Disease and Therapeutic Index on Syncope and Collapse,ICD-9-CM 780.2,IMS America,1997,2 Blanc J-J,Lher C,Touiza A,et al.Eur Heart J,2002;23:815-820.,3 Day SC,et al,AM J of Med 1982,4 Kapoor W.Evaluation and outcome of patients with syncope.Medicine 1990;69:160-175,The Significance of Syncope,1,National Disease and Therapeutic Index on Syncope and Collapse,ICD-9-CM 780.2,IMS America,1997,2,Blanc J-J,Lher C,Touiza A,et al.Eur Heart J,2002;23:815-820.,3,Day SC,et al,AM J of Med 1982,4,Kapoor W.Evaluation and outcome of patients with syncope.Medicine 1990;69:160-175,1,Day SC,et al.,Am J of Med,1982;73:15-23.,2,Kapoor W.,Medicine,1990;69:160-175.,3,Silverstein M,Sager D,Mulley A.,JAMA,.1982;248:1185-1189.,4,Martin G,Adams S,Martin H.,Ann Emerg Med.,1984;13:499-504.,Some causes of syncope are potentially fatal,Cardiac causes of syncope have the highest mortality rates,The Significance of Syncope,短暂的意识丧失(,TLOC),晕厥 特点,发作前可有不同的先兆。,发作突然，,多在站立或坐位时发生。,意识丧失为自限性，常伴有肌张力增高。,意识可迅速恢复。,苏醒无后遗症。,机制：一过性脑灌注减少,.,Brignole M,et al.,Europace,2004;6:467-537.,晕厥的原因,体位性低血压,心律失常,心肺病变,1,VVS,CSS,Situational,Cough,Post-,Micturition,2,Drug-Induced,ANS Failure,Primary,Secondary,3,Brady,SN Dysfunction,AV Block,Tachy,VT,SVT,Long QT Syndrome,4,Acute Myocardial Ischemia,Aortic Stenosis,HCM,Pulmonary Hypertension,Aortic Dissection,神经介导,Unexplained Causes=Approximately 1/3,DG Benditt,MD.U of M Cardiac Arrhythmia Center,其他病因和类似病症,先天性心脏病、主动脉窦瘤破入右心,吞咽性晕厥,脑部因素：,TIA、,癫痫、椎基底动脉供血不足、偏头痛、脑部 肿瘤,代谢因素：重度贫血、脱水、电解质紊乱、低血糖。,内分泌因素：甲状腺、肾上腺病变。,呼吸系统因素：窒息、哮喘。,精神因素：,过渡换气：,急性中毒：酒精、药物。,Cardiac Rhythms During Unexplained Syncope,Seidl K.,Europace,.2000;2(3):256-262.,Krahn AD.,PACE,.2002;25:37-41.,Medtronic ILR Replacement Data.FY03,04.On file.,No Recurrence 36%(31-48%),Normal Sinus Rhythm 31%(17-44%),Other 11%,Arrhythmia 22%,(13-32%),Tachycardia 6%(2-11%),Bradycardia 16%(11-21%),Composite:N=133 to 7109,晕 厥 诊 断,诊断目的,是否晕厥,有无心脏病,病因诊断,估计预后,制定预防和治疗措施,详细病史,近期发生情况,发生前状态、目击证人介绍,发生前和发生时症状,后遗症,医生检查和治疗情况,过去发生情况,伴随疾病,家族史,心脏病,猝死,代谢疾病,过去药物治疗情况,神经系统病史,晕厥,Brignole M,et al.,Europace,2004;6:467-537.,体格检查,生命体征,心率,不同体位血压,心血管检查,神经系统检查,颈动脉窦按摩,Brignole M,et al.,Europace,2004;6:467-537.,颈动脉窦按摩,(CSM),方法,1,按摩,5-10s,不要使颈动脉闭塞,卧位和直立位（倾斜床上,),结果,心脏停博3,s,和或者收缩压下降,50 mmHg,伴有症状,=,颈动脉综合症,禁忌征,2,颈动脉明显病变,既往有脑卒中,近3个月有,MI,并发症,神经系统表现,发病率小于,0.2%,3,通常是短暂的,1,Kenny RA.,Heart,.2000;83:564.,2,Linzer M.,Ann Intern Med,.1997;126:989.,3,Munro N,et al.,J Am Geriatr Soc,.1994;42:1248-1251.,其他检查,心电图：,心脏成像检查,心脏彩超、冠脉造影。,心电监测,Holter,Event recorder,Intermittent vs.Loop,Insertable Loop Recorder(ILR),Brignole M,et al.,Europace,2004;6:467-537.,Heart Monitoring Options,ILR,Event Recorders,(non-lead and loop),Holter Monitor,12-,Lead,2,Days,7-30,Days,Up to 14 Months,10,Seconds,OPTION,TIME(Months),0,1,2,3,4,5,6,7,8,9,10,11,12,13,14,Brignole M,et al.,Europace,2004;6:467-537.,ATP,试验：可短暂使血管迷走神经张力增高,电生理检查,(EPS),倾斜试验,脑电图,头颅,CT,头颅,MRI,可能有助诊断癫痫,颈椎,MRI,其他检查,电生理检查价值,老年人或者有心脏猝死病史意义较大。,健康人没有心脏猝死病史意义较小。,阳性发现,:,诱发单形,VT,SNRT 3000 ms or CSNRT 600 ms,诱发,SVT,同时合并低血压,HV,间期,100 ms,起搏诱发房室结以下传导阻滞,Benditt D.In:Topol E,ed.,Textbook of Cardiovascular Medicine,.Lippencott;2002:1529-1542.,Lu F,et al.In:Benditt D,et al.,The Evaluation and Treatment of Syncope,.Futura.2003;80-95.,Brignole M,et al.,Europace,.2004;6:467-537.,电生理检查局限性,很难判断自发晕厥和实验室发现是否相关,阳性率,1,无心脏猝死者：,6-17%,有心脏猝死者,:25-71%,快速心律失常比缓慢心律失常有价值,2,EPS,发现必须与病史相结合,注意假阳性,1,Linzer M,et al.,Ann Int Med,.1997;127:76-86.,2,Lu F,et al.In:Benditt D,et al.,The Evaluation and Treatment of Syncope,.Futura.2003;80-95.,正常人当体位由平卧 头高倾斜立位,静脉回流减少,心室充盈下降,减少了（与脑干迷走背核直接相连系的）心室后下壁纤维 的激活,反射性地增加了交感输出,结果心跳加快,周围血管阻力增高。所以,体位直立的正常反应是心率增快,舒张压升高,收缩压轻度升高。,倾斜试验（机制）,60-80,VVS,患者当体位由平卧转成头高倾斜立位,静脉回流减少,心室充盈量快速下降，,心室强烈收缩,，心室排空现象，激活心室后下壁,C,纤维，冲动传导 脑干迷走中枢，,迷走活动增强，血压下降心率减慢。,倾斜试验（机制）,60-80,血压下降标准为收缩压,80,和,(,或,),舒张压,50,或平均动脉压下降,25%,。,有的患者即使血压未达到此标准,但已出现晕厥或接近晕厥症状,仍应判为阳性。,倾斜试验阳性标准（血压）,60-80,倾斜试验阳性标准（心率）,窦性心动过缓(50次/分)、窦性停搏,交界性逸搏心律,度及以上房室传导阻滞,3秒以上的心脏停搏。,倾斜试验评价,60 70倾斜角度 ,试验的特异性可达 9 0%;,60角倾斜 45分钟,者阳性率约 30%50%;,加用异丙肾上腺素激发试验,可使特异性降低。,加用异丙肾上腺素,试验阳性率可达 85%9 0%。,反复发作频繁的患者应给予治疗。,受体阻滞剂,可阻滞儿茶酚胺的作用,降低纤维的刺激,丙吡胺也可应用,它通过抗胆碱能和负性肌力作用而达治疗目的。,茶碱类对抗腺苷介导的低血压和心动过缓,因此也有治疗作用。,氟氢考的松为盐皮质酮,具有保钠、扩容作用,可能减少发作。,以心脏抑制型为主,而药物效果不好者,可考虑置入双腔起搏器。,的药物治疗,诊断评价,(N=341,1,to 433,2,),References Available,结果,(%),评价指标,病史,体检,ECG,心脏成像,38-40,其他检查,倾斜试验,27,体外心电监测,5-13,Insertable Loop Recorder(ILR),43-88,3-5,电生理检查,35%,60,Patients,AECG,Tilt,EP Study,Diagnosis,ILR,+,+,ILR,Conventional Testing(AECG,Tilt,EPS),30,Patients,30,Patients,PrimaryStrategy,Crossover,14,6,1,8,+,+,ISSUE,I,nternational,S,tudy of,S,yncope of,U,ncertain,E,tiology,Multicenter,international,prospective study,Analyzed the diagnostic contribution of an ILR in three predefined groups of patients with syncope of uncertain origin:,Isolated syncope:No SHD,Normal ECG,1,Negative tilt,Positive tilt,Patients with heart disease and negative EP test,2,Patients with bundle branch block and negative EP test,3,1,Moya A.,Circulation.,2001;104:1261-1267.,2,Menozzi C,et al.,Circulation,.2002;105:2741-2745.,3,Brignole M,et al.,Circulation,.2001;104:2045-2050.,ISSUE,Patients with Isolated Syncope and Tilt-Positive Syncope,Moya A.,Circulation.,2001;104:1261-1267.,Follow-Up to Recurrent Spontaneous Episode,111,Patients with Syncope,No SHD,Normal ECG,29:,Tilt-Positive,82:,Tilt-Negative“Isolated Syncope”,Tilt Test Followed by,Insertable Loop Recorder,ISSUE,Patients with Heart Disease and a Negative EP Test,Menozzi C,et al.,Circulation,.2002;105:2741-2745.,35,Pts with Heart Diseaseand Insertable Loop Recorder,Syncope:6 Pts(17%),ECG-Documented:6 Pts(17%),Pre-Syncope:13 Pts(37%),ECG-Documented:8 Pts(23%),AV block+asystole:1,A.Fib+asystole:1,Sinus arrest:1,Sinus tachycardia:1,Rapid A.Fib:2,Sustained VT:1,Parox.A.Fib/AT:1,Post tachycardia pause:1,No rhythm variations:4,Sinus tachycardia:1,ISSUE,Patients with Heart Disease and a Negative EP Test,Conclusions,Patients with unexplained syncope,overt heart disease,and negative EP study had a favorable medium-term outcome,Mechanism of syncope was heterogeneous,Ventricular tachyarrhythmia was unlikely,“ILR-guided strategy seems reasonable,with specific therapy safely delayed until a definite diagnosis is made.”,Menozzi C,et al.,Circulation,.2002;105:2741-2745.,ISSUE,Patients with Bundle Branch Block and Negative EP Test,Brignole M.,ET AL.,Circulation.,2001;104:2045-2050.,*5,of these also had 1 presyncope,*Drop-out before primary-end point,52,Pts with BBBand Insertable Loop Recorder,Syncope:22 Pts(42%)*,ILR-Detected:19,AVB:12(63%),SA:4(21%),Asystole-undefined:1(5%),NSR:1(5%),Sinus tachy:1(5%),Not Detected:3,Stable AVB:3 Pts(6%),ILR-DetectedPre-Syncope:2 Pts(4%)*,Death:1 Pt(2%),AVB:2(4%),ISSUEPatients with Bundle Branch Block and Negative EP Test,Conclusion:,In patients with BBB and negative EP study,most syncopal recurrences have a homogeneous mechanism that is characterized by prolonged asystolic pauses mainly attributable to sudden-onset paroxysmal AV block,Brignole M.,Circulation.,2001;104:2045-2050.,Section III:,Specific Conditions and Treatment,Specific Conditions,Cardiac arrhythmia,Brady/Tachy,Long QT syndrome,Torsade de pointes,Brugada,Drug-induced,Structural cardio-pulmonary,Neurally-mediated,Vasovagal Syncope(VVS),Carotid Sinus Syndrome(CSS),Orthostatic,Cardiac Syncope,Includes cardiac arrhythmias and SHD,Often life-threatening,May be warning of critical CV disease,Tachy and brady arrhythmias,Myocardial ischemia,aortic stenosis,pulmonary hypertension,aortic dissection,Assess culprit arrhythmia or structural abnormality aggressively,Initiate treatment promptly,Brignole M,et al.,Europace,.2004;6:467-537.,“,cardiac syncope can be a harbinger of sudden death.”,Survival with and without syncope,6-month mortality rate of greater than 10%,Cardiac syncope doubled the risk of death,Includes cardiac arrhythmias and SHD,No Syncope,Vasovagal andOther Causes,Cardiac Cause,051015,Follow-Up(yr),Probability of Survival,1.0,0.8,0.6,0.4,0.2,0.0,Soteriades ES,et al.,N Engl J Med.,2002;347:878.,Syncope Due to Structural Cardiovascular Disease:Principle Mechanisms,Acute MI/Ischemia,2 neural reflex bradycardia Vasodilatation,arrhythmias,low output(rare),Hypertrophic cardiomyopathy,Limited output during exertion(increased obstruction,greater demand),arrhythmias,neural reflex,Acute aortic dissection,Neural reflex mechanism,pericardial tamponade,Pulmonary embolus/pulmonary hypertension,Neural reflex,inadequate flow with exertion,Valvular abnormalities,Aortic stenosis Limited output,neural reflex dilation in periphery,Mitral stenosis,atrial myxoma Obstruction to adequate flow,Brignole M,et al.,Europace,.2004;6:467-537.,Syncope Due to Cardiac Arrhythmias,Bradyarrhythmias,Sinus arrest,exit block,High grade or acute complete AV block,Can be accompanied by vasodilatation(VVS,CSS),Tachyarrhythmias,Atrial fibrillation/flutter with rapid ventricular rate(eg,pre-excitation syndrome),Paroxysmal SVT or VT,Torsade de pointes,Brignole M,et al.,Europace,.2004;6:467-537.,ILR Recordings,CASE:28 year-old man presents to ER multiple times after falls resulting in trauma.VT:Ablated and medicated.,CASE:83 year-old woman with syncope due to bradycardia:Pacemaker implanted.,Reveal,ILR recordings;Medtronic data on file.,Long QT Syndromes,Mechanism,Abnormalities of sodium and/or potassium channels,Susceptibility to polymorphic VT(Torsade de pointes),Prevalence,Drug-induced forms Common,Genetic forms Relatively rare,but increasingly being recognized,“Concealed”forms:,May be common,Provide basis for drug-induced torsade,Schwartz P,Priori S.In:Zipes D and Jalife J,eds.,Cardiac Electrophysiology,.Saunders;2004:651-659.,Syncope:Torsade de Pointes,From the files of DG Benditt,MD.U of M Cardiac Arrhythmia Center,Long QT Syndromes:12-Lead ECG,From the files of DG Benditt,MD.U of M Cardiac Arrhythmia Center,Drug-Induced QT Prolongation,(List is continuously being updated),Antiarrhythmics,Class IA.Quinidine,Procainamide,Disopyramide,Class IIISotalol,Ibutilide,Dofetilide,Amiodarone,NAPA*,Antianginal Agents,Bepridil*,Psychoactive Agents,Phenothiazines,Amitriptyline,Imipramine,Ziprasidone,Antibiotics,Erythromycin,Pentamidine,Fluconazole,Ciprofloxacin and its relatives,Nonsedating antihistamines,Terfenadine*,Astemizole,Others,Cisapride*,Droperidol,Haloperidol,*,Removed from U.S.Market,Brignole M,et al.,Europace,2004;6:467-537.,Treatment of Long QT,Suspicion and recognition are critical,Emergency treatment,Intravenous magnesium,Pacing to overcome bradycardia or pauses,Isoproterenol to increase heart rate and shorten repolarization,ICD if prior SCA or strong family history,If drug induced:,Reverse bradycardia,Withdraw drug,Avoid ALL long-QT provoking agents,If genetic:,Avoid ALL long-QT provoking agents,For more information visit www.longqt.org,Schwartz P,Priori S.In:Zipes D and Jalife J,eds.,Cardiac Electrophysiology,.Saunders;2004:651-659.,Treatment of Syncope Due to Bradyarrhythmia,Class I indication for pacing using dual chamber system wherever possible,Ventricular pacing in atrial fibrillation with slow ventricular response,ACC/AHA/NASPE 2002 Guideline Update.,Circ,.2002;106:2145-2161.,nV,0.4,0.2,0.0,-0.2,-0.4,:45,:44,:43,:42,:41,:40,:39,:38,:37,:37,:36,:35,:34,:33,:32,:31,:30,:29,:29,:28,:27,:26,:25,:24,:23,:22,:21,08:23:21,8:23:29,08:23:37,0.4,0.2,0.0,-0.2,-0.4,0.4,0.2,0.0,-0.2,-0.4,Treatment of Syncope Due to Tachyarrhythmia,Atrial tachyarrhythmias,AVRT due to accessory pathway Ablate pathway,AVNRT Ablate AV nodal slow pathway,Atrial fib Pacing,linear/focal ablation for paroxysmal AF,Atrial flutter Ablate the IVC-TV isthmus of the re-entrant circuit for typical flutter,Ventricular tachyarrhythmias,Ventricular tachycardia ICD or ablation where appropriate,Torsade de pointes Withdraw offending drug or implant ICD(long QT/Brugada/short QT),Drug therapy may be an alternative in many cases,Brignole M,et al.,Europace,.2004;6:467-537.,Neurally-Mediated Reflex Syncope,Vasovagal Syncope(VVS),Carotid Sinus Syndrome(CSS),Situational syncope,Post-micturition,Cough,Swallow,Defecation,Blood drawing,etc.,Brignole M,et al.,Europace,2004;6:467-537.,Pathophysiology,Autonomic Nervous System,Benditt D,et al.,Neurally mediated syncope:Pathophysiology,investigations and treatment,.Blanc JJ,et al.eds.Futura.1996.,VVSClinical Pathophysiology,Neurally-mediated physiologic reflex mechanism with two components:,1.Cardioinhibitory (HR),2.Vasodepressor (BP)despite heart beats,no significant BP generated,Both components are usually present,Wieling W,et al.In:Benditt D,et al.,The Evaluation and Treatment of Syncope,.Futura.2003;11-22.,1,2,VVSIncidence,Most common form of syncope,8%to 37%(mean 18%)of syncope cases,Depends on population sampled,Young without SHD,incidence,Older with SHD,incidence,Linzer M,et al.,Ann Intern Med.,1997;126:989.,VVS vs.CSS,In general:,VVS patients younger than CSS patients,Ages range from adolescence to older adults(median 43 years),Linzer M,et al.,Ann Intern Med.,1997;126:989.,VVS Recurrences,1,Savage D,et al.,STROKE.,1985;16:626-29.,2,Sheldon R,et al.,Circulation.,1996;93:973-81.,35%,of patients report syncope recurrence during follow-up 3 years,1,Positive HUT with 6 lifetime syncope episodes:recurrence risk 50%over 2 years,2,1000,800,50,100,25,8,4,2,1,1,2,3,6,24,84,480,Months Since Symptoms Began,Two Year Risk,Total Number of Syncopal Episodes,75%,50-75%,25-50%,2 hours,ECG and continuous blood pressure,supine,and upright,Tilt to 70,20 minutes,Isoproterenol/Nitroglycerin if necessary,End point Loss of consciousness,60-80,Benditt D,et al.,JACC,.1996;28:263-275.,Brignole M,et al.,Europace,2004;6:467-537.,VVS General Treatment Measures,Optimal treatment strategies for VVS are a source of debate,Treatment goals,Acute intervention,Physical maneuvers,eg,crossing legs or tugging arms,Lowering head,Lying down,Long-term prevention,Tilt training,Education,Diet,fluids,salt,Support hose,Drug therapy,Pacing,Brignole M,et al.,Europace,2004;6:467-537.,VVS Tilt Training Protocol,Objectives,Enhance orthostatic tolerance,Diminish excessive autonomic reflex activity,Reduce syncope susceptibility/recurrences,Technique,Prescribed periods of upright posture against a wall,Start with 3-5 min BID,Increase by 5 min each week until a duration of 30 min is achieved,Reybrouck T,et al.,PACE,.2000;23(4 Pt.1):493-498.,VVS Tilt Training:Clinical Outcomes,Treatment of recurrent VVS,Reybrouck,et al.,*,:Long-term study,38 patients performed home tilt training,After a period of regular tilt training,82%remained free of syncope during the follow-up period,However,at the 43-month follow-up,29 patients had abandoned the therapy,Conclusion:The abnormal autonomic reflex activity of VVS can be remedied.Compliance may be an issue.,*,Reybrouck T,et al.,PACE.,2000;23:493