Pii: s1062-1458(01)00215-x

Arrhythmias
Neurocardiogenic Syncope: When and
How to Treat?
afforded considerable latitude in planning therapy based on Blair Grubb, MD and Daniel J. Kosinski, MD, the patient’s clinical circumstance.
Electrophysiology Section, Division of Cardiology, In addition, it is our opinion that any patient with Department of Medicine, The Medical College of Ohio, neurocardiogenic syncope and clinical episodes that occur while in the seated position require treatment. These pa-tients are at risk for syncope during activities such asdriving or operating other vehicles, industrial equipment, Neurocardiogenic syncope is a very common cause of syn- etc. In these individuals, the customary method of lying cope. In some patient populations, such as children and down in order to abort an episode is often ineffective and/or adolescents, it is the most common cause of syncope. Yet, despite numerous publications on the subject, decisions ontreatment of the disorder remain ambiguous.
In patients with frequent episodes of neurocardiogenic Treatment
syncope, the decision to treat is obvious. However, in Numerous treatment modalities have been shown to be patients with a single or infrequent episode(s), the decision effective in neurocardiogenic syncope. The physician must to treat is often times very difficult. If such patients have a choose a treatment plan based on the patient’s age, tilt clear precipitant, such as phlebotomy, treatment beyond response, comorbidities and other medications the patient education may not be necessary. In most patients with a single or infrequent episode(s), we look principally at two If at all possible, nonpharmacologic treatment should be clinical factors. The first factor we consider is whether or employed. The first issue to consider is whether or not the not a reasonable prodrome of symptoms occurred prior to patient is taking medication that can be prosyncopal. Such syncope. The second clinical factor is the lifestyle and/or medications would include diuretics, vasodilators and/or occupation of the patient. For instance, a patient with a centrally acting agents such as MAO inhibitors or tricyclic sedentary lifestyle and two syncopal episodes usually does antidepressants. If such medications can safely be reduced not require treatment if the episodes occur with a 30 – 60 or withdrawn, this should be considered.
second prodrome. This would allow the patient time to sit Education should be provided encouraging the patient or lie down and thus avoid injury. Conversely, a truck to avoid volume depletion. The patient should be advised to driver with a single episode would be appropriate to treat if moderately increase salt intake and to sit or lie down at the the episode occurred with little or no prodrome. We realize first sign of an impending event. However, this type of these guidelines are vague. However, the decision to treat in advice is sometimes unhelpful. Some patients have little or these cases is often difficult, and physicians should be no prodrome warning and in other patients, salt loading Table 1. Therapy for neurocardiogenic syncope
Medication/Typical Dose
Mechanism of Action
Advantages
Disadvantages
Prozac 20 mg qdPaxil 20 mg qdYohimbine 8 mg bid–tid 2001 by the American College of Cardiology and/or volume expansion may be inadvisable for other reasons such as supine hypertension.
Nonpharmacologic therapy can include elastic support In patients with neurocardiogenic syncope, decisions on hose. These hose should best be ordered to be thigh high when to treat and how to treat are based more on individual with 30 – 40 mm Hg counter pressure. However, this form issues than randomized trial data. Although guidelines do of therapy has several drawbacks including aesthetic issues exist, a premium remains on thoughtful clinical judgment tailored to the patient’s circumstance.
Finally, in some patients, orthostatic training, provided by standing upright against a wall twice daily for varying Suggested Reading
Kosinski D, Grubb BP. Vasodepressor syncope. Current Treat- ment Options in Cardiovascular Medicine 2000; 2:309 –15.
Pharmacologic Therapy
Bloomfield D, Sheldon R, Grubb BP, et al. Putting it all together: A new treatment algorithm for vasovagal syncope and related A summary of various pharmacologic options is listed in disorders. Am J Cardiol 1999;84:33Q–9Q.
Table 1. While choosing a particular therapy, attention Connolly S, Sheldon R, Roberts M. The North American vasovagal must be paid to several factors. The physician must con- pacemaker study. A randomized trial of permanent cardiac sider the patient’s age, other illnesses and medications, side pacing for the prevention of vasovagal syncope. J Am Coll Cox M, Peelman B, Mayor R. Acute and long-term ␤-adrenergic blockade for patients with neurocardiogenic syncope. J Am Cardiac Pacing
The role of cardiac pacing to treat neurocardiogenic syn- Grubb BP, Kosinski D, Boehm K, Kip K. Postural orthostatic cope remains controversial. It is reserved for patients in tachycardia syndrome: A neurocardiogenic variant identifiedduring head up tilt testing. PACE 1997;20:2205–12.
whom episodes include a substantial bradycardic compo- DiGirolamo E, DiForio C, Leonizio L, et al. Usefulness of a tilt nent. In general, these patients are also refractory to phar- training program for the prevention of refractory neurocardio- macologic therapy. However, some patients may prefer genic syncope in adolescents. Circulation 1999;100:1798 – When pacing is utilized, a dual-chamber pacer with Grubb BP, Kosinski D. Dysautonomic and reflex syncope syn- hysteresis or rate-drop function should be utilized. In ad- dromes. Cardio Clinics 1997;15:257– 63.
dition, patients should be advised that pacing alone may be Address correspondence and reprint requests to Daniel J. Kosinski, ineffective and that they may require adjunctive medical MD, Cardiology, Room 1192, The Medical College of Ohio, 3000 Arling-

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