Minerva medica
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Syncope is a common presenting complaint to the emergency department (ED). Its assessment is difficult. Some serious causes of syncope are transient and patients with a potentially life threatening condition may appear well by the time they reach the ED. ⋯ It is likely that serious outcome in syncope although significant, is not quite as common as previously thought. Presently the American College of Emergency Physician (ACEP) guidelines are the most useful guidelines written for the emergency physician. With biochemical markers showing some promise, further work may lead to incorporation of these into existing clinical decision rules and guidelines to improve their sensitivity and specificity.
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Since its first description in 1992 as a new clinical entity, the Brugada syndrome has stimulated great interest among physicians and basic scientists. In 2002 and 2005, two consensus conferences have respectively defined the diagnostic criteria for the syndrome. Currently the diagnosis of Brugada syndrome is based on a combination of clinical events (syncope and/or sudden cardiac death due to malignant ventricular arrhythmias) and electrocardiographic features (pathognomonic ST-segment elevation morphology). ⋯ Syncope is ubiquitously recognized as a bad prognostic marker in Brugada syndrome. However, young individuals with this disease may suffer from vaso-vagal instead of arrhythmic syncope. The prognostic significance of syncope in patients with Brugada syndrome is discussed in this review.
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Vasovagal syncope (VVS) is the commonest cause of syncope accounting for up to 60% of all cases. The head-up tilt-table test (HUTT) was first described as a diagnostic test for VVS in 1986 and is now in widespread use as a research and diagnostic tool. Vasovagal syncope was previously thought to be confined to younger patients but with the introduction of HUTT, it is now being diagnosed with greater frequency in the elderly. ⋯ Individuals with typical presentations and infrequent episodes do not require investigation with HUTT as history alone is often diagnostic. The head-up tilt-table test is, however, required with atypical features, seizure activity, occupational issues, and is more likely to be required in older patients. The practicalities of conducting the HUTT and limitations of HUTTs are also discussed.