晕厥的病因和诊断策略陈庆华

晕厥的病因和诊断策略,郑州大学第一附属医院心内科,陈庆华,The Significance of Syncope,1 National Disease and Therapeutic Index on Syncope and Collapse, ICD-9-CM 780.2, IMS America, 19972 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 19824 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 fatalCardiac 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,1VVSCSSSituationalCoughPost- Micturition,2Drug-Induced ANS FailurePrimarySecondary,3BradySN DysfunctionAV BlockTachyVTSVTLong QT Syndrome,4 Acute Myocardial IschemiaAortic StenosisHCMPulmonary HypertensionAortic 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,1Kenny RA. Heart. 2000;83:564.2Linzer M. Ann Intern Med. 1997;126:989.3Munro 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 recorderIntermittent vs. LoopInsertable 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 VTSNRT 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,1Linzer M, et al. Ann Int Med. 1997;127:76-86.2Lu 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）,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）,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）,倾斜试验阳性标准（心率）,窦性心动过缓 ( 6 lifetime syncope episodes: recurrence risk 50% over 2 years2,From the files of DG Benditt, MD. U of M Cardiac Arrhythmia Center,VVS Spontaneous,16 year-old male, healthy, athletic, monitored for fainting.,VVSDiagnosis,History and physical exam, ECG and BPHead-Up Tilt (HUT) Protocol: Fast 2 hoursECG and continuous blood pressure, supine, and uprightTilt to 70, 20 minutesIsoproterenol/Nitroglycerin if necessaryEnd 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 debateTreatment goalsAcute interventionPhysical maneuvers, eg, crossing legs or tugging armsLowering headLying down,Long-term preventionTilt trainingEducationDiet, fluids, salt Support hoseDrug therapyPacing,Brignole M, et al. Europace, 2004;6:467-537.,VVS Tilt Training Protocol,ObjectivesEnhance orthostatic toleranceDiminish excessive autonomic reflex activityReduce syncope susceptibility/recurrences Technique Prescribed periods of upright posture against a wallStart with 3-5 min BIDIncrease 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 study38 patients performed home tilt trainingAfter a period of regular tilt training, 82% remained free of syncope during the follow-up periodHowever, 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;23:493-498.,VVS Tilt Training: Clinical Outcomes,Foglia-Manzillo, et al.*: Short-term study68 patients35 tilt training33 no treatment (control)Tilt table test conducted after 3 weeks19 (59%) of tilt trained and 18 (60%) of controls had a positive testTilt training was not effective in reducing tilt testing positivity ratePoor compliance in the majority of patients with recurrent VVS,*Foglio-Manzillo G, et al. Europace. 2004;6:199-204.,VVS Pharmacologic Treatment,Fludrocortisone Beta-adrenergic blockersPreponderance of clinical evidence suggests minimal benefit1SSRI (Selective Serotonin Re-Uptake Inhibitor)1 small controlled trial2Vasoconstrictors1 negative controlled trial (etilefrine)32 positive controlled trials (midodrine)4,5,1Brignole M, et al. Europace, 2004;6:467-537.2Di Girolamo E, et al. JACC. 1999;33:1227-1230.3Raviele A, et al. Circ. 1999;99:1452-1457.,4Ward C, et al. Heart. 1998;79:45-49.5Perez-Lugones A, et al. J Cardiovasc Electrophysiol. 2001;12(8):935-938.,Midodrine for VVS,Perez-Lugones A, Schweikert R, Pavia S, et al. J Cardiovasc Electrophysiol. 2001;12(8):935-938.,Months,p 0.001,Symptom-Free Interval,0,Fluid,Midodrine,The Role of Pacing as Therapy for Syncope,VVS with +HUT and cardioinhibitory response:Class IIb indication for pacingThree randomized, prospective trials reported benefits of pacing in select VVS patients:VPS I1VASIS2SYDIT3Subsequent study results less clearVPS II4Synpace5INVASY6,1Connolly SJ. J Am Coll Cardiol. 1999;33:16-20.2Sutton R. Circulation. 2000;102:294-299.3Ammirati F. Circ. 2001;104:52-57.,4Connolly S. JAMA. 2003;289:2224-2229.5Giada F. PACE . 2003;26:1016 (abstract).6Occhetta E, et al. Europace. 2004;6:538-547.,VPS I (North American Vasovagal Pacemaker Study),Objective: To evaluate pacemaker therapy for severe recurrent vasovagal syncopeRandomized, prospective, single centerN=54 patients27: DDD pacemaker with rate drop response 27: No pacemakerInclusion: Vasodepressor responsePrimary outcome: First recurrence of syncope,Connolly SJ. J Am Coll Cardiol. 1999;33:16-20.,100,90,80,70,60,50,40,30,20,10,0,0,3,6,9,12,15,Time in Months,No Pacemaker (PM),2P=0.000022,Pacemaker,Cumulative Risk (%),Connolly SJ. J Am Coll Cardiol. 1999;33:16-20.,Results:6 (22%) with PM had recurrence vs. 19 (70%) without PM84% RRR (2p=0.000022),VPS I (North American Vasovagal Pacemaker Study),VASIS (VAsovagal Syncope International Study),Objective: To evaluate pacemaker therapy for severe cardioinhibitory tilt-positive neurally mediated syncopeRandomized, prospective, multi-centerN=42 patients19: DDI pacemaker (80 bpm) with rate hysteresis (45 bpm)23: No pacemakerInclusion: Positive cardioinhibitory responsePrimary outcome: First recurrence of syncope,Sutton R. Circulation. 2000;102:294-299.,Sutton R. Circulation. 2000;102:294-299.,Pacemaker (PM),No Pacemaker,p=0.0004,Years,% Syncope-Free,100,80,60,40,20,0,2,3,4,5,6,Results:1 (5%) with PM had recurrence vs. 14 (61%) without PM,VASIS (VAsovagal Syncope International Study),SYDIT (SYncope DIagnosis and Treatment),Objective: To compare the effects of cardiac pacing with pharmacological therapy in patients w