Sincope en el anciano (nov 2014)

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<p>Presentacin de PowerPoint</p> <p>Sncope en el Anciano Dr. Jos Mejas MCardilogo-Electrofisilogo MTSVC </p> <p>Sncope (Griego: synkope = cortar) Breve y transitoria prdida de la consciencia y del tono postural con recuperacin rpida y espontnea. </p> <p>SINCOPE</p> <p>Incidence of syncope in the Framingham Heart StudyFrom 1997-2000 National Health Ambulatory Medical Survey of ED visits in USA.2.63 million ED pt.( 0.65% of all visits) with the diagnosis of syncope unrelated to injury1.1 million pt.(40.8%) were 65 yrs or older63.8% were femaleAmong pt. older than 65 yrs, admit rate for syncope was 61.8% and was the sixth most common admission diagnosis</p> <p>7</p> <p>8</p> <p>9Cambios morfolgicos y fisiolgicos dependientes de la edad.Los Ancianos toman diversos frmacos (Sedantes, Hipotensores, Diurticos, Vasodilatadores etc)Los Ancianos tienen mayor incidencia de patologas crnicas como Hipertensin, Diabetes, Insuficiencia cardiaca, Enfermedad coronaria, patologa cerebrovascular y multiples deficiencias sensoriales </p> <p>ClassificationSyncopeNeurally Mediated 34%VasovagalCarotid SinusSituationalGlossopharyngeal NeuralgiaCerebrovascularAutonomic FailureCardiac Mediated 18%ArrythmiaSrtructural Heart DiseaseCardiopulmonary DiseaseOthers 47%Orthostatic HypotensionIdiopathicMedicationsPsychiatric</p> <p>14</p> <p>Sncope ReflejoEl Sncope VasoVagal clsico es diagnsticado si el sncope es precipitado por Estres emocional (Miedo, Dolor intenso, Fobia a la sangre, instrumentacin) o por estar en una posicin largo tiempo y esta asociado con tpicos sntomas prodrmicos debido a activacin autonmica (Palidez, sudoracin, nauseas, molestias abdominals, mareos etc)Sncope Situacional es diagnsticado si el sncope ocurre durante o inmediatamente despus de una accin especfica (Orinar, Defecar, dolor abdominal, Postprandial, relacionada con tos o con la risa)</p> <p>Sncope CardiovascularSncope Cardiovascular es diagnsticado con el ECG realizado en la evaluacin inicial cuando el sncope se presenta en pacientes con Mixomas u otros tumors intracardacos, Estenosis Artica severa , Hipertensin Pulmonar, Embolismo pulmonar u otros estados hipxicos, Diseccin Aortica aguda, Taponamiento pericardico, Miocardiopata Hipertrofica Obstructiva y Vlvulas Protsicas disfuncionantes.Sncope relacionado con ArritmiasSncope relacionado con Arritmias es diagnsticado por el ECG (incluyendo monitoreo continuo) cuando hay : Bradicardia Sinusal 3 sBloqueo AV de II grado Mobitz II o Bloqueo AV de III gradoBloqueo alternante de Rama Derecha o IzquierdaTaquicardia Supraventricular o VentricularMarcapasos o DAI malfuncionantes con pausas cardiacasSncope relacionada con Isquemia MiocardicaEl sncope relacionado con isquemia Miocardica es diagnsticado cuando los sntomas coinciden con evidencias electrocardiogrficas de Isquemia aguda con o sin Infarto del Miocardio.</p> <p>Classification of Syncope According to Etiology (Modified by ESC Guidelines)Versus Classification According to Mechanism (Modified by ISSUE Classification)Sncope OrtostticoEl Sncope Ortosttico es diagnsticado cuando la historia clinica es consistente con el diagnstico y hay documentacin de Hipotensin Ortosttica durante el examen fsico (Definido usualmente como una disminucin de la PAS 20 mmHg o a una disminucin de la PAS 30 mmHg es necesario en pacientes hipertensos).</p> <p>European Heart Journal (2009) 30, 26312671QUE DEBEMOS HACER ANTE UN PACIENTE CON SNCOPE ?EVALUACION INICIAL En la Emergencia HISTORIA CLINICA DETALLADA</p> <p>EXAMEN FISICO</p> <p>ECG</p> <p>ECOCARDIOGRAM (Si Disponible)Initial evaluation: the value of history taking and standard ECGDiagnosis was established in 50% of patients evaluated in the ED and in 21% of the more difficult patients referred to specialized syncope units. Reflex syncope (vasovagal, situational) accounted for approximately 2/3 of the diagnoses in both settings. Arrhythmic syncope was the second most frequent cause of syncope, accounting for 10% of the cases.</p> <p>Short-Term High-Risk Criteria That Require Prompt Hospitalization or Early Intensive Evaluation</p> <p>Short-Term High-Risk Criteria That Require Prompt Hospitalization or Early Intensive Evaluation</p> <p>The Diagnostic Algorithm of a PatientPresenting With TLOC of Suspected Syncopal NatureLaboratory Provocative TestsTilt-table testing and carotid sinus massage are indicated when reflex syncope is suspected in the setting of an atypical presentation.Electrophysiological study is indicated when cardiac arrhythmic syncope is suspected such as in patients with previous MI, nondiagnostic sinus bradycardia, BBB, or history of sudden and brief episodes of palpitations preceding the syncopal event. Exercise testing is indicated in patients who experience syncope during or shortly after exertion and in patients with chest pain suggestive of CAD.ECG monitoring is useful soon after the index episode in selected patients who have frequent symptoms such as weekly occurrences.</p> <p>Carotid Sinus MassageStimulation of hypersensitive carotid body can produce 3 main responses</p> <p>Cardio-inhibitory response (70%)</p> <p>Vasodepressor response (10%)</p> <p>Mixed (20%)38</p> <p>TILT TABLE TEST</p> <p>40</p> <p>Normal test</p> <p>44Cardioinhibitory response </p> <p>45</p> <p>Vasodepressor responseBP drops from 150/70 to 50/30 but heart rate stays same</p> <p>47Mixed responseBP drops from 150/60 to 50/20 while HR drops from 65 to 30bpm</p> <p>48</p> <p>Monitoring Continuum</p> <p>PronsticoEl Pronstico en el paciente con Sncope es frecuentemente relacionado a la severidad de la Enfermedad subyacente y no al evento sincopal per se. En el Anciano la Enfermedad structural cardiaca y la Hipotensin Postural estan asociadas a un incremento del riesgo de Muerte debido a comorbilidades. </p> <p>Clasificacin y TratamientoLa eficacia del tratamiento es mayormente determinado por el mecanismo del sncope mejor que por su etiologa.Dado el mejor pronstico con terapia guiada por el mecanismo, la clasificacin del Sncope basada en su mecanismo probablemente ser la ms ampliamente utilizada en el paciente con Sncope.Management of Neurally Mediated Syncope</p> <p>Grubb BP. NEJM. 2005. 352(10): 1004-101056MANAGEMENTPatient education and counsellingAvoid triggersIncrease in salt and fluid intakeSleeping with the head of the bed raised (6-12 inches.Elastic stockingsPreventing LOC or InjuryAssume supine position upon onset of prodromeAvoid driving or other activities that could lead to injury</p> <p>57 Postural hypotensionExclude treatable causes then:EducationRaise bed headCompression stockingsIncrease salt intakeFludrocortisone 50 mcg nocte initiallyFlurbiprofenDesmopressinMidodrine oral alpha agonist58</p> <p>DISCORDIAS EN LA EVALUACION DEL SINCOPE NEUROLOGO CARDIOLOGO</p> <p>EQUIPOS DE TRABAJO</p>