Diagnostik von Synkopen des älteren Herzpatienten

Zusammenfassung

Physiologische Veränderungen, Komorbidität und häufige Polypharmakotherapie prädisponieren ältere Patienten zu Synkopen. Obwohl diese Patienten die größte Gruppe von Patienten mit Synkopen darstellen, bleibt die Ursache oft ungeklärt. Aus diesem Grund ist eine systematische Abklärung erforderlich, um therapeutisch einzugreifen. Neben den anamnestischen Angaben des Patienten und der Angehörigen stellen eine gründliche klinische Untersuchung einschließlich der Blutdruckmessung im Liegen und im Stehen sowie ein Standard 12-Kanal-EKG die ersten diagnostischen Schritte dar. Die Entscheidung über die Notwendigkeit zusätzlicher - apparativer - Untersuchungen hängt insbesondere von Hinweisen darüber ab, ob eine kardiale Erkrankung vorliegt oder nicht. Ohne Nachweis einer kardialen Grunderkrankung stellen Kipptischuntersuchung und Tests der autonomen Funktion die weiteren Schritte dar. Weitergehende kardiale Untersuchung sind dagegen insbesondere bei Patienten mit dokumentierter oder vermuteter Herzerkrankung indiziert. Externe oder implantierbare EKG Rekorder stellen einen wichtigen Fortschritt bei der Detektion seltener (Brady- oder Tachy) Arrhythmien dar. Die Prognose wird weitgehend durch die zugrundeliegende (Herz) Erkrankung bestimmt.

Summary

Age-related physiologic changes, a higher prevalence of chronic illness, and concomitant (often multiple) medication account for a higher susceptibility of elderly patients to syncope. Although elderly patients are the largest group with syncope, the causes frequently remain unclear. Multifactorial causes, lack of witnesses, overlap with falls, and additional cognitive impairment often confound the assessment of syncope in the elderly. Thus, strategic investigation is often needed to establish the diagnosis and to unmask the cause. In addition to a comprehensive medical history (by both patient and witnesses), a thorough physical examination including supine and standing blood pressure measurements and a standard 12 lead ECG remain the mainstay of diagnosis. The decision whether additional tests are needed depends on indications whether organic heart disease is present or not. Without evidence of structural heart disease, tilt table testing and studies of autonomic function are the next steps. In contrast, additional cardiac investigation (including invasive studies) is needed in patients with suspected or documented cardiac disease. External or implantable loop recorders represent a significant improvement in the diagnosis of rare episodes of (brady- or tachy)-arrhythmias. Prognosis is determined by the underlying (heart) disease.

Literatur

• 1 Castelli R, Tarsia P, Tantardini C. et al . Syncope in patients with pulmonary embolism: comparison between patients with syncope as the presenting symptom of pulmonary embolism and patients with pulmonary embolism without syncope.  Vasc Med. 2003;  8 257-261
• 2 Crane S D. Risk stratification of patients with syncope in an accident and emergency department.  Emerg Med J. 2002;  19 23-27
• 3 Croci F, Brignole M, Alboni P. et al . The application of a standardized strategy of evaluation in patients with syncope referred to three syncope units.  Europace. 2002;  4 351-355
• 4 Davies A J, Kenny R A. Falls presenting to the accident and emergency department: types of presentation and risk factor profile.  Age Ageing. 1996;  25 362-366
• 5 Fitzpatrick A P, Theodorakis G, Vardas P. et al . Methodology of head-up tilt testing in patients with unexplained syncope.  J Am Coll Cardiol. 1991;  17 125-130
• 6 Kapoor W N. Current evaluation and management of syncope.  Circulation. 2002;  106 1606-1609
• 7 Kenny R A. Syncope in the elderly: diagnosis, evaluation, and treatment.  J Cardiovasc Electrophysiol. 2003;  14 S74-S77
• 8 Kenny R A, Richardson D A, Steen N. et al . Carotid sinus syndrome: a modifiable risk factor for nonaccidental falls in older adults (SAFE PACE).  J Am Coll Cardiol. 2001;  38 1491-1496
• 9 Krahn A D, Klein G J, Yee R. et al . Cost implications of testing strategy in patients with syncope: randomized assessment of syncope trial.  J Am Coll Cardiol. 2003;  42 495-501
• 10 Krahn A D, Klein G J, Yee R. et al . Randomized assessment of syncope trial: conventional diagnostic testing versus a prolonged monitoring strategy.  Circulation. 2001;  104 46-51
• 11 Menozzi C, Brignole M, Tomasi C. et al . Carotid sinus syncope: the most frequent neurally mediated syncope in the elderly.  Arch Gerontol Geriatr. 1995;  20 7-14
• 12 Sarasin F P, Hanusa B H, Perneger T. et al . A risk score to predict arrhythmias in patients with unexplained syncope.  Acad Emerg Med. 2003;  10 1312-1317
• 13 Sarasin F P, Louis-Simonet M, Carballo D. et al . Prevalence of orthostatic hypotension among patients presenting with syncope in the ED.  Am J Emerg Med. 2002;  20 497-501
• 14 Seidl K, Drogemuller A, Rameken M. et al . Two year follow-up in 643 patients with non-invasively unexplained syncope and therapy guided by electrophysiologic study.  Z Kardiol. 2003;  92 852-861
• 15 Shen W K, Decker W W, Smars P A, Goyal D G, Walker A E, Hodge D O, Trusty J M, Brekke K M, Jahangir A, Brady P A, Munger T M, Gersh B J, Hammill S C, Frye R L. Syncope evaluation in the emergency department study (SEEDS). A multidisciplinary approach to syncope management.  Circulation. 2004;  110 3636-3645
• 16 Solano A, Menozzi C, Maggi R. et al . Incidence, diagnostic yield and safety of the implantable loop-recorder to detect the mechanism of syncope in patients with and without structural heart disease.  Eur Heart J. 2004;  25 1116-1119
• 17 Soteriades E S, Evans J C, Larson M G. et al . Incidence and prognosis of syncope.  N Engl J Med. 2002;  347 878-885
• 18 Sutton R, Brignole M, Menozzi C. et al . Dual-chamber pacing in the treatment of neurally mediated tilt-positive cardioinhibitory syncope : pacemaker versus no therapy: a multicenter randomized study. The Vasovagal Syncope International Study (VASIS) Investigators.  Circulation. 2000;  102 294-299
• 19 Task force on syncope ESC . Guidelines on management (diagnosis and treatment) of syncope - update 2004.  Europace. 2004;  6 467-537