Mascioli G, Anzola G P, Morandini A, Raddino R, Turelli A, Curnis A, Cicogna R
Divisione di Cardiologia, Ospedale, Vallecamonica, Esine (BS).
Cardiologia. 1996 May;41(5):455-63.
Many mechanisms of different nature-hemodynamic, metabolic and reflex-may cause syncope. We have studied all patients referred for syncope to the Divisions of Cardiology and Neurology of our Hospital, focusing five end-points: standardize a diagnostic protocol; evaluate the diagnostic value of the different tools in the diagnosis of syncope; evaluate the causes of syncope in our patients; value the importance of systematic cardiological-neurological co-operation in these patients; observe the prognosis of patients with syncopal attacks. We have studied 330 patients referred to our Divisions for syncopal attacks (239 in Cardiology and 91 in Neurology) with a protocol organized in 4 steps of increasing levels of complexity: step 1: history, clinical examination, standard electrocardiogram, carotid sinus massage, chest radiography, neurological and cardiological examination; step 2: two-dimensional Doppler echocardiography, dynamic 24-72 hour ECG, standard electroencephalogram (EEG), head-up tilt-table test; step 3: EEG after sleep deprivation, computed tomography, Doppler evaluation of carotid flows, transesophageal electrophysiologic study (EPS); step 4: Oxford test for 24-hour evaluation of arterial blood pressure, intracavitary EPS. We have found in 165 patients (50%) a cardiac syncope, in 78 (23.6%) a reflex syncope, in 43 patients (13%) a syncope of different origin ("non cardiac-non reflex") and in 44 patients (13.4%) we have not been able to find a cause of patient's syncopal attacks. We have established a diagnosis in 148 patients (51.7% of diagnoses) with step 1 examinations, in 98 cases (34.2%) with step 2, in 33 (11.5%) with step 3 and in 7 (2.5%) with step 4 examinations. One hundred-twenty three patients - or relatives of died patients-(37.3%) have answered our follow-up questionnaire (mean follow-up 54.85 +/- 13.73 months, range 36-78 months). Among them, patients with cardiac syncope have had a mortality rate of 18.57%, those with reflex syncope of 7.69%, those with "non cardiac-non reflex" syncope of 7.14%. No patients with syncope of unknown origin died. Our study demonstrates that in the evaluation of patients with syncope, the simplest diagnostic tools are of great value: in fact we have obtained 86% of the diagnoses with the first 2 steps examinations. Furthermore, our study confirms that cardiac syncope has a higher mortality rate compared to other forms of syncope. Co-operation between our Divisions has not been very useful in increasing the number of diagnosed cases, but it has allowed to correctly and rapidly direct our attention toward one form of syncope so that we have been able to speed up the diagnostic process.
多种不同性质的机制——血液动力学、代谢和反射性机制——可能导致晕厥。我们对转诊至我院心脏病科和神经科的所有晕厥患者进行了研究，重点关注五个终点：规范诊断方案；评估不同工具在晕厥诊断中的诊断价值；评估我们患者晕厥的原因；重视这些患者中系统的心脏科 - 神经科合作的重要性；观察晕厥发作患者的预后。我们按照四个复杂性逐渐增加的步骤对转诊至我科的330例晕厥发作患者（心脏病科239例，神经科91例）进行了研究：第一步：病史、临床检查、标准心电图、颈动脉窦按摩、胸部X线摄影、神经科和心脏科检查；第二步：二维多普勒超声心动图、动态24 - 72小时心电图、标准脑电图（EEG）、头高位倾斜试验；第三步：睡眠剥夺后的脑电图、计算机断层扫描、颈动脉血流多普勒评估、经食管电生理研究（EPS）；第四步：用于24小时动脉血压评估的牛津试验、心腔内EPS。我们发现165例患者（50%）为心源性晕厥，78例（23.6%）为反射性晕厥，43例患者（13%）为不同原因的晕厥（“非心源性 - 非反射性”），44例患者（13.4%）我们未能找到患者晕厥发作的原因。通过第一步检查我们对148例患者（诊断的51.7%）做出了诊断，第二步检查98例（34.2%），第三步检查33例（11.5%），第四步检查7例（2.5%）。123例患者——或死亡患者的亲属——（37.3%）回答了我们的随访问卷（平均随访54.85±13.73个月，范围36 - 78个月）。其中，心源性晕厥患者的死亡率为18.5%，反射性晕厥患者为7.69%，“非心源性 - 非反射性”晕厥患者为7.14%。不明原因晕厥患者无死亡病例。我们的研究表明，在晕厥患者的评估中，最简单的诊断工具具有很大价值：实际上，我们通过前两步检查获得了86%的诊断。此外，我们的研究证实，与其他形式的晕厥相比，心源性晕厥的死亡率更高。我们科室之间的合作在增加确诊病例数量方面并不是非常有用，但它使我们能够正确且迅速地将注意力转向一种晕厥形式，从而能够加快诊断过程。
