eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology

Syncope: Multimedia

Author: M Silvana Horenstein, MD, Consulting Staff, Department of Pediatrics, University of Texas Medical School Houston; Medical Doctor Consultant, Legacy Department, Best Doctors, Inc
Coauthor(s): Robert Murray Hamilton, MD, MSc, FRCPC, Section Head, Electrophysiology, Director, High-Risk Hereditary Heart Conditions Clinic, Labatt Family Heart Centre; Professor, Department of Pediatrics, Associate Scientist, Physiology and Experimental Medicine, The Hospital for Sick Children and Research Institute, University of Toronto, Canada
Contributor Information and Disclosures

Updated: Nov 11, 2009

Multimedia

ECG rhythm strip of lead II obtained during a til...
(Enlarge Image)
Media file 1: ECG rhythm strip of lead II obtained during a tilt test in a 15-year-old female with a history of syncope. At the beginning of the study she had normal sinus rhythm and the blood pressure was normal based on noninvasive manometry. Fourteen minutes into the study, the blood pressure dropped due to venous pooling into the lower extremities. This caused an increase in catecholamine release, which increased her heart rate and, likely, her cardiac contractility.

This produced reflex bradycardia through what is believed to be enhanced parasympathetic activity (35 s later), which produced a marked decrease in blood pressure because of decreased cardiac filling and reflex sympathetic withdrawal with further vasodilation and enhanced parasympathetic activity. Enhanced parasympathetic activity led to 4.4 seconds of asystole during which the blood pressure was too low to be recorded. The patient then had a very brief syncopal episode, and during horizontal repositioning she developed supraventricular escape rhythm. Therefore, she was diagnosed as having the cardioinhibitory form of neurally mediated syncope with severe bradycardia causing hypotension.
[ CLOSE WINDOW ]
ECG rhythm strip of lead II obtained during a til...

ECG rhythm strip of lead II obtained during a tilt test in a 15-year-old female with a history of syncope. At the beginning of the study she had normal sinus rhythm and the blood pressure was normal based on noninvasive manometry. Fourteen minutes into the study, the blood pressure dropped due to venous pooling into the lower extremities. This caused an increase in catecholamine release, which increased her heart rate and, likely, her cardiac contractility.

This produced reflex bradycardia through what is believed to be enhanced parasympathetic activity (35 s later), which produced a marked decrease in blood pressure because of decreased cardiac filling and reflex sympathetic withdrawal with further vasodilation and enhanced parasympathetic activity. Enhanced parasympathetic activity led to 4.4 seconds of asystole during which the blood pressure was too low to be recorded. The patient then had a very brief syncopal episode, and during horizontal repositioning she developed supraventricular escape rhythm. Therefore, she was diagnosed as having the cardioinhibitory form of neurally mediated syncope with severe bradycardia causing hypotension.

More on Syncope

Overview: Syncope
Differential Diagnoses & Workup: Syncope
Treatment & Medication: Syncope
Follow-up: Syncope
Multimedia: Syncope
References
[ CLOSE WINDOW ]

References

  1. Mark AL. The Bezold-Jarisch reflex revisited: clinical implications of inhibitory reflexes originating in the heart. J Am Coll Cardiol. Jan 1983;1(1):90-102. [Medline].

  2. Silver ES, Pass RH, Hordof AJ, Liberman L. Paroxysmal AV block in children with normal cardiac anatomy as a cause of syncope. Pacing Clin Electrophysiol. Mar 2008;31(3):322-6. [Medline].

  3. [Guideline] Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol. May 27 2008;51(21):e1-62. [Medline].

  4. Driscoll DJ, Jacobsen SJ, Porter CJ, Wollan PC. Syncope in children and adolescents. J Am Coll Cardiol. Apr 1997;29(5):1039-45. [Medline].

  5. Vignati G, Annoni G. Characterization of supraventricular tachycardia in infants: clinical and instrumental diagnosis. Curr Pharm Des. 2008;14(8):729-35. [Medline].

  6. Frustaci A, Priori SG, Pieroni M. Cardiac histological substrate in patients with clinical phenotype of Brugada syndrome. Circulation. Dec 13 2005;112(24):3680-7.

  7. Schwartz PJ, Spazzolini C, Crotti L, et al. The Jervell and Lange-Nielsen syndrome: natural history, molecular basis, and clinical outcome. Circulation. Feb 14 2006;113(6):783-90. [Medline].

  8. Chandar JS, Wolff GS, Garson A, et al. Ventricular arrhythmias in postoperative tetralogy of Fallot. Am J Cardiol. Mar 1 1990;65(9):655-61. [Medline].

  9. Nakazawa M, Shinohara T, Sasaki A, et al. Arrhythmias late after repair of tetralogy of fallot: a Japanese Multicenter Study. Circ J. Feb 2004;68(2):126-30. [Medline].

  10. Vohra J, Sathe S, Warren R, et al. Malignant ventricular arrhythmias in patients with mitral valve prolapse and mild mitral regurgitation. Pacing Clin Electrophysiol. Mar 1993;16(3 Pt 1):387-93. [Medline].

  11. Al Dhahri KN, Potts JE, Chiu CC, Hamilton RM, Sanatani S. Are Implantable Loop Recorders Useful in Detecting Arrhythmias in Children with Unexplained Syncope?. Pacing Clin Electrophysiol. Aug 19 2009;[Medline].

  12. Aldor E, Heeger H. Ventricular fibrillation under quinidine medication--quinidine syncope. Med Klin. Mar 3 1978;73(9):325-8. [Medline].

  13. Balaji S, Oslizlok PC, Allen MC, et al. Neurocardiogenic syncope in children with a normal heart. J Am Coll Cardiol. Mar 1 1994;23(3):779-85. [Medline].

  14. Boehm KE, Morris EJ, Kip KT, et al. Diagnosis and management of neurally mediated syncope and related conditions in adolescents. J Adolesc Health. Jan 2001;28(1):2-9. [Medline].

  15. Borggrefe M, Wolpert C, Antzelevitch C, et al. Short QT syndrome. Genotype-phenotype correlations. J Electrocardiol. Oct 2005;38(4 Suppl):75-80. [Medline].

  16. Bunce NH, Lorenz CH, Keegan J, et al. Coronary artery anomalies: assessment with free-breathing three-dimensional coronary MR angiography. Radiology. Apr 2003;227(1):201-8. [Medline]. [Full Text].

  17. Carniel E, Sinagra G, Bussani R, et al. Fatal myocarditis: morphologic and clinical features. Ital Heart J. Sep 2004;5(9):702-6. [Medline].

  18. Clark CT, Resenblatt R, Somberg JC. Neurocardiogenic syncope with Addison's disease. Am J Ther. Sep 2000;7(5):328-31. [Medline].

  19. Cooper LT, Berry GJ, Shabetai R. Idiopathic giant-cell myocarditis--natural history and treatment. Multicenter Giant Cell Myocarditis Study Group Investigators. N Engl J Med. Jun 26 1997;336(26):1860-6. [Medline].

  20. Dallengach-Hellweg G. [Morphologically demonstrable bases of a) normal menstruation and its disturbances b) nidation c) detachment of the placenta during birth]. Verh Dtsch Ges Pathol. 1976;375-81. [Medline].

  21. Davis AM, Wilkinson JL. The long QT syndrome and seizures in childhood. J Paediatr Child Health. Oct 1998;34(5):410-1. [Medline].

  22. De Rosa G, Piastra M, Pardeo M, et al. Exercise-unrelated sudden death as the first event of anomalous origin of the left coronary artery from the right aortic sinus. J Emerg Med. Nov 2005;29(4):437-41. [Medline].

  23. Eckart RE, Jones SO, Shry EA, et al. Sudden death associated with anomalous coronary origin and obstructive coronary disease in the young. Cardiol Rev. Jul-Aug 2006;14(4):161-3. [Medline].

  24. Fruhwald FM, Eber B, Schumacher M, et al. Syncope in dilated cardiomyopathy is a predictor of sudden cardiac death. Cardiology. May-Jun 1996;87(3):177-80. [Medline].

  25. Grubb BP. Cerebral syncope: new insights into an emerging entity. J Pediatr. Apr 2000;136(4):431-2. [Medline].

  26. Hauer KE. Discovering the cause of syncope. A guide to the focused evaluation. Postgrad Med. Jan 2003;113(1):31-8, 95; quiz 2. [Medline].

  27. Johnsrude CL. Current approach to pediatric syncope. Pediatr Cardiol. Nov-Dec 2000;21(6):522-31. [Medline].

  28. Knight BP, Goyal R, Pelosi F, et al. Outcome of patients with nonischemic dilated cardiomyopathy and unexplained syncope treated with an implantable defibrillator. J Am Coll Cardiol. Jun 1999;33(7):1964-70. [Medline].

  29. Kumpf M, Sieverding L, Gass M, et al. Anomalous origin of left coronary artery in young athletes with syncope. BMJ. May 13 2006;332(7550):1139-41. [Medline].

  30. Lewis DA, Dhala A. Syncope in the pediatric patient. The cardiologist's perspective. Pediatr Clin North Am. Apr 1999;46(2):205-19. [Medline].

  31. McElhinney DB, Chatterjee KM, Reddy VM. Double-chambered right ventricle presenting in adulthood. Ann Thorac Surg. Jul 2000;70(1):124-7. [Medline].

  32. Mohindra R, Pannu HS, Mohan B, et al. Syncope in a middle aged male due to acute rheumatic fever. Indian Heart J. Nov-Dec 2004;56(6):668-9. [Medline].

  33. Morin MJ, Hopkins RA, Ferguson WS, Ziegler JW. Intracardiac yolk sac tumor and dysrhythmia as an etiology of pediatric syncope. Pediatrics. Apr 2004;113(4):e374-6. [Medline]. [Full Text].

  34. Oh JH, Kapoor WN. Psychiatric illness and syncope. Cardiol Clin. May 1997;15(2):269-75. [Medline].

  35. Papper EM. A democratic education--an excercise in collegiality. (A possible view of Diogenes were he to examine our present educational process). J Fla Med Assoc. Dec 1979;66(12):1219-21. [Medline].

  36. Patel ND, Singh BK, Mathew ST. The heterogeneous spectrum of the long QT syndrome. Eur J Intern Med. Jul 2006;17(4):235-40. [Medline].

  37. Patel RA, DiMarco JP, Akar JG, et al. Chagas myocarditis and syncope. J Cardiovasc Magn Reson. 2005;7(4):685-8. [Medline].

  38. Probst V, Evain S, Gournay V, et al. Monomorphic ventricular tachycardia due to Brugada syndrome successfully treated by hydroquinidine therapy in a 3-year-old child. J Cardiovasc Electrophysiol. Jan 2006;17(1):97-100. [Medline].

  39. Rogers SO, Leacche M, Mihaljevic T, et al. Surgery for anomalous origin of the right coronary artery from the left aortic sinus. Ann Thorac Surg. Nov 2004;78(5):1829-31. [Medline].

  40. Rosenfeld ME, Beckerman B, Ward MF, Sama A. Lyme carditis: complete AV dissociation with episodic asystole presenting as syncope in the emergency department. J Emerg Med. Jul-Aug 1999;17(4):661-4. [Medline].

  41. Samoil D, Grubb BP, Kip K, Kosinski DJ. Head-upright tilt table testing in children with unexplained syncope. Pediatrics. Sep 1993;92(3):426-30. [Medline].

  42. Shonk JR, Vogel-Claussen J, Halushka MK, et al. Giant cell myocarditis depicted by cardiac magnetic resonance imaging. J Comput Assist Tomogr. Nov-Dec 2005;29(6):742-4. [Medline].

  43. Tanel RE, Walsh EP. Syncope in the pediatric patient. Cardiol Clin. May 1997;15(2):277-94. [Medline].

  44. Vasiljevic Z, Dmitrovic R, Naumovic Z, et al. Common form of Lyme borreliosis carditis--complete heart block with syncope: report on 3 cases. Cardiology. Jan-Feb 1996;87(1):76-8. [Medline].

  45. Webb CL, Dick M, Rocchini AP, et al. Quinidine syncope in children. J Am Coll Cardiol. May 1987;9(5):1031-7. [Medline].

  46. Wieling W, Smit AA, de Jong-de Vos van Steenwijk CC, et al. Pathophysiological mechanisms underlying vasovagal syncope in young subjects. Pacing Clin Electrophysiol. Aug 1997;20(8 Pt 2):2034-8. [Medline].

  47. Wolff GS. Unexplained syncope: clinical management. Pacing Clin Electrophysiol. Aug 1997;20(8 Pt 2):2043-7. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

syncope, faint, common faint, loss of consciousness, vasovagal syncope, vasodepressor syncope, neuroregulatory syncope, neurogenic syncope, neurocardiogenic syncope, presyncope, atrial fibrillation, supraventricular tachycardia, SVT, pulmonary hypertension

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

M Silvana Horenstein, MD, Consulting Staff, Department of Pediatrics, University of Texas Medical School Houston; Medical Doctor Consultant, Legacy Department, Best Doctors, Inc
M Silvana Horenstein, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Robert Murray Hamilton, MD, MSc, FRCPC, Section Head, Electrophysiology, Director, High-Risk Hereditary Heart Conditions Clinic, Labatt Family Heart Centre; Professor, Department of Pediatrics, Associate Scientist, Physiology and Experimental Medicine, The Hospital for Sick Children and Research Institute, University of Toronto, Canada
Robert Murray Hamilton, MD, MSc, FRCPC is a member of the following medical societies: American Heart Association, Canadian Cardiovascular Society, Canadian Medical Association, Canadian Medical Protective Association, Cardiac Electrophysiology Society, Heart Rhythm Society, Ontario Medical Association, Pediatric Electrophysiology Society, Royal College of Physicians and Surgeons of Canada, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Ira H Gessner, MD, Professor Emeritus, Pediatric Cardiology
Ira H Gessner, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Pediatric Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

John W Moore, MD, MPH, Professor of Clinical Pediatrics, Section of Pediatric Cardiology, Department of Pediatrics, University of California San Diego School of Medicine; Director of Cardiology, Rady Children's Hospital
John W Moore, MD, MPH is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

CME Editor

Gilbert Z Herzberg, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Cardiology, New York Medical College; Consulting Staff, Department of Pediatrics, Sound Shore Medical Center
Gilbert Z Herzberg, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Chief Editor

Stuart Berger, MD, Professor of Pediatrics, Division of Cardiology, Medical College of Wisconsin; Chief of Pediatric Cardiology, Medical Director of Pediatric Heart Transplant Program, Medical Director of The Heart Center, Children's Hospital of Wisconsin
Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.