Handbook of Syncope: A Concise Clinical Approach Behzad B Pavri
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1Handbook of Syncope: A Concise Clinical Approach2
3Handbook of Syncope: A Concise Clinical Approach
Behzad B Pavri MD FACC Professor of Medicine Director, CCEP Fellowship Thomas Jefferson University Hospital Philadelphia, USA Foreword Andrew E Epstein
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Handbook of Syncope: A Concise Clinical Approach
First Edition: 2014
9789350909539
Printed at
5Dedications
To my beloved wife Alice, for her infinite grace, patience, and guidance
To my dear mother Beroz, for shaping my character in my formative years
To my fellows, past, present, and future
9Foreword
Andrew E Epstein md faha facc fhrs
Electrophysiology Section, Division of Cardiovascular Medicine
University of Pennsylvania Philadelphia PA 19104 USA
Syncope is no small problem. It accounts for up to 5% of emergency room visits, and many of these patients are admitted with an annual cost in the United States of billions of dollars. Nearly half of us readers will experience syncope in our lifetime. Thus, this Handbook addresses a problem that is far from trivial. While there are textbooks and reviews in specialty journals on the evaluation and management of syncope, a current and up-to-date guide for the clinician to use at the bedside is not readily available. In this context, each chapter that follows here is short, focused, and to the point. Each is easy to read, and the bullet point style will be extremely helpful to readers wanting focused review of this subject. Numerous tables, figures and ECG tracings illustrate common and uncommon findings in patients with syncope. Each chapter ends with summary points that provide “take-home” messages for the topic being discussed. There are over 250 references listed for the reader who may desire additional reading. The Handbook will not only be helpful to new practitioners in their learning phase but also to those “on the front line”. To have this text on the shelf in Emergency Rooms provides an immediate resource for the differential diagnosis of syncope.
Dr Pavri importantly emphasizes the importance of the history, so often ignored in contemporary practice when reliance is placed in tests that are expensive, not helpful, and indeed sometimes ordered for legal protection. The bedside is where the diagnosis of the cause of syncope is most likely made. In the chapter on the approach to syncope, the lists of questions to be posed to the patient and witnesses are extremely helpful. Indeed, they are worthy of review even for the seasoned clinician as a reminder of what stones to not leave unturned. And the figures, especially the rhythm strips and ECGs are a wonderful compendium of examples of common and uncommon arrhythmic causes of the symptom. After these basics are described, further testing is nicely reviewed covering tilt table testing, stress testing especially when syncope is exercise-related, and electrophysiologic studies emphasizing that the majority of syncope is not neurologic in origin such that the routine ordering of head CT scans and EEGs is not in order.
We all worry about the legal aspects of medicine, and syncope is a charged subject. The chapter on the medicolegal aspects of syncope is therefore especially important, and this information neither generally known nor easily accessible in one place. For example, what 10evaluation is necessary to discharge someone from an emergency department, when should a patient be admitted, are physicians required to report syncope to driver's licensing agencies, and what about commercial driving? Although beyond the scope of this Handbook, we all need to learn the laws specific to the states in which we live since for noncommercial driving the laws are different in each state. For commercial driving, the rules are determined on a national basis by the Department of Transportation (DOT) and the Federal Motor Carrier Safety Administration (FMCSA). Regarding syncope during sports activities, referral to a specialist is virtually always warranted since it is often indicative of a genetic (arrhythmia syndrome) or structural cause (hypertrophic or other cardiomyopathy, anomalous coronary artery, etc.).
Since vasovagal syncope is the most common cause of syncope, a single chapter is appropriately given to this subject. Single chapters are also devoted to bradycardic and tachycardic causes of syncope. Finally, for those interested in more information about the areas covered in the Handbook, excellent references are provided. Since syncope is common, we will all see patients presenting with this complaint. For that reason alone, this Handbook is a welcome addition.
11Preface
As vertical life forms on this planet, human beings are constantly battling gravity in order to achieve adequate cerebral perfusion. Over the eons of evolution, complex mechanisms and swift reflexes have evolved to ensure cephalad blood flow, no matter what our body position or hydration status, in order to maintain consciousness. Any perturbation in this amazing and self-adjusting system may result in transient loss of consciousness. Therefore, syncope will always remain a common affliction of human beings.
Why another publication on syncope? Clearly, there are already numerous, multi-author books on the subject. This Handbook was borne out of nearly two decades of observing medical students, residents, fellows, and busy clinicians in hospitals, outpatient offices, and emergency rooms encountering patients with syncope, and their uncertainty of how exactly to proceed. The Handbook strives to provide physicians-in-training and clinicians a succinct guide to those aspects that are most meaningful in arriving at the correct diagnosis. For today's harried doctors, perpetually juggling time obligations, a greater reliance on tests, imaging, and investigations can be a natural outcome. For exactly this reason, the Handbook stresses the importance of a detailed history and thorough physical examination in reaching the correct diagnosis in syncopal patients. Because the ECG plays a central role, there are multiple examples provided with detailed descriptions. In cases of diagnostic uncertainty, the Handbook provides simple guidelines to allow recognition of higher risk patients who would benefit from further evaluation and hospital admission.
M O'Donnell, in “A skeptic's medical dictionary”, humorously defined clinical experience as “Making the same mistakes with increasing confidence over an impressive number of years”. The Handbook aspires to share the personal and observed “mistakes” accumulated over 2 decades of clinical practice in academic institutions, so as to improve outcomes in the common condition of syncope.
Behzad B Pavri
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13Acknowledgements
The author gratefully acknowledges the editorial and proofreading support by Alice Pavri.