Diagnosis and management of patients with blackouts

Heart

Volumn 92, Issue 4, 2006, Pages 559-568

  Fitzpatrick, Adam P ^a   Cooper, Paul ^b,c  

^a Manchester Heart Centre   (United Kingdom)

^b HOPE HOSPITAL   (United Kingdom)

^c David Lewis Centre for Epilepsy   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

CLINICAL EXAMINATION; COLLAPSE; DIFFERENTIAL DIAGNOSIS; ECHOCARDIOGRAPHY; ELECTROCARDIOGRAM; EPILEPSY; HEART PACING; HUMAN; PREVALENCE; PRIORITY JOURNAL; PSYCHOGENESIS; REVIEW; SYNCOPE; SYSTEMATIC REVIEW; TILT TABLE TEST;

EID: 33645237318     PISSN: 13556037     EISSN: None     Source Type: Journal    
DOI: 10.1136/hrt.2005.068650     Document Type: Review

References (26)

1. Kapoor WN. Evaluation and outcome of patients with syncope. Medicine 1990;69:160-75.
2. Eagle KA, Black HR, Cook EF, et al. Evaluation of prognostic classification for patients with syncope Am J Med 1985;79:455-60.
3. Day SC, Cook EF, Funkenstein H, et al. Evaluation and outcome of emergency room patients with transient loss of consciousness. Am J Med 1982;73:15-23.
4. Sander JWAS, Shorvon SD. Epidemiology of the epilepsies. J Neurol Neurosurg Psychiatry 1996;61:433-43. A concise reference article for classification of the epilepsy syndromes.
5. Smith D, Defalla BA, Chadwick DW. The misdiagnosis of epilepsy and the management of refractory epilepsy in a specialist clinic. Q J M 1999;92:15-23. Beacon UK publication highlighting the problem of the misdiagnosis of epilepsy in neurology clinics.
6. Zaidi A, Clough P, Cooper P, et al. Misdiagnosis of epilepsy: many seizure like attacks have a cardiovascular cause. J Am Coll Cardiol 2000;36:181-4. Landmark paper showing that many patients misdiagnosed with epilepsy in fact have syncope.
7. Smith D, Defalla BA, Chadwick DW. The misdiagnosis of epilepsy and the management of refractory epilepsy in a specialist clinic. Q J M 1999;92:15-23.
8. Soteriades ES, Evans JC, Larson MG, et al. Incidence and prognosis of syncope. N Engl J Med 2002;347:878-5. This paper from the USA, and reference 9, confuses T-LOC with syncope. Syncope is a cause of T-LOC, as is epilepsy.
9. Chen-Scarabelli C, Scarabelli TM. Neurocardiogenic syncope. BMJ 2004;329:336-41.
10. Almquist A, Goldenberg IF, Milstein S, et al. Provocation of bradycardia and hypotension by isoproterenol and upright posture in patients with unexplained syncope. N Engl J Med 1989;321:346-51. Early landmark study showing the effect of head-up tilt in reproducing symptoms in unexplained syncope.
11. Fitzpatrick AP, Banner N, Cheng A, et al. Vasovagal reactions before and after re-innervation in patients with orthotopic cardiac transplantation. J Am Coll Cardiol 1993;21:1132-7. Report of studies of Kit table testing in heart transplant recipients, showing that reflex syncope could be produced in spite of cardiac denervation.
12. Parry SW, Steen IN, Baptist M, et al. Amnesia for loss of consciousness in carotid sinus syndrome: implications for presentation with falls. J Am Coll Cardiol 2005;45:1840-3. Important work showing that many elderly patients with falls have had a blackout precipitating the fall, and that they later cannot recall the initial blackout.
13. Kapoor WN, Karpf M, Weant S, et al. A prospective evaluation and follow-up of patients with syncope. N Engl J Med 1983;309:197-203. Much quoted landmark study with prospective follow-up of syncope patients. The high cost of admission, investigation, and low yield are highlighted. Also highlighted are the outcomes of syncope with and without structural heart disease. About 50% of patients are undiagnosed despite 10 days in hospital and costly investigations.
14. Zaidi A, Crampton S, Clough P, et al. Head-up tilting is a useful provocative test for psychogenic non-epileptic seizures. Seizure 1999;6:353-5. Use of tilt table testing to diagnose psychogenic seizures or non-epileptic attack disorder (NEAD).
15. Slater JO, Brown MC, Jacobs W, et al. Induction of pseudoseizures with intravenous saline placebo. Epilepsia 1995;36:580-5. Use of intravenous saline injection to precipitate NEAD has aroused some debate about ethical considerations or tricking patients.
16. Gibson TC, Heitzman MR. Diagnostic efficacy of 24-hour electrocardiography monitoring for syncope. Am J Cardiol 1984;53:1013-7. Large study of 24 hour Holter monitoring in syncope, showing yield of
17. Linzer M, Pritchett EL, Pontinen M, et al. Incremental diagnostic yield of loop electrocardiographic recorders in unexplained syncope. Am J Cardiol 1990;66:214-9. Yield of external loop recorders varies from about 10-30% in T-LOC.
18. Fitzpatrick AP, Lee RJ, Epstein LM, et al. Effect of patient characteristics on the yield of prolonged baseline head-up tilt-testing and the additive yield of drug provocation. Heart 1996;76:406-11. The only known "all comers" study of Hit testing in T-LOC. Shows that the tilt lest response depends upon the pre-test likelihood of a positive or negative test, and that overall yield in T-LOC is about 20%, as against 10% in controls. Shows that drug provocation after baseline unmedicated tilt has a low additive yield.
19. Krahn AD, Klein GJ, Yee R, et al. Randomized assessment of syncope trial: conventional diagnostic testing versus a prolonged monitoring strategy. Circulation 2001;104:46-51. Randomised study showing that the yield of implantable ECG monitoring in syncope is independent of tilt table testing result.
20. Stokes W. Observations on some cases of permanently slow pulse. Dublin Q J M Sci 1846;2:73-4. Original description of the Stokes-Adam attack caused by heart Mock.
21. Lesser RP. Treatment and outcome of psychogenic nonepileptic seizures. Epilepsy Curr 2003;3:198-200. Useful review of the background to psychogenic seizures, which may account for 5-15% of T-LOC.
22. Fitzpatrick AP, Theodorakis G, Ahmed R, et al. Methodology of head-up tilt in the investigation of unexplained syncope. J Am Coll Cardiol 1991;17:125-30. Early work showing a high yield in elderly patients with syncope and no structural heart disease (70%), a low yield in controls with syncope caused by heart block or sick sinus syndrome (10%), but a low reproducibility of tilt table testing within patients. Also demonstrated was the need for the angle of tilt to be 60° or greater.
23. Grubb BP, Samoil D, Kosinski D, et al. Fluoxetine hydrochloride for the treatment of severe refractory orthostatic hypotension. Am J Med 1994;97:366-8. Unrandomised, uncontrolled study of medical treatment for reflex syncope showing benefits.
24. Fitzpatrick AP, Ahmed R, Williams S, et al. A randomised trial of medical therapy for vasodepressor vasovagal syncope. Eur J Pacing Electrophysiol 1991;2:43-8. Randomised, placebo controlled, double blind crossover study of clonidine, scopolamine patches and atenolol treatment for reflex syncope showed no benefits over placebo.
25. Madrid AH, Ortega J, Rebollo JG, et al. Lack of efficacy of atenolol for the prevention of neurally mediated syncope in a highly symptomatic population: a prospective, double-blind, randomized and placebo-controlled study. J Am Coll Cardiol 2001;37:554-9. Randomised, placebo controlled, double blind study of atenolol for treatment for reflex syncope showed no benefits over placebo.
26. Ward CR, Gray JC, Gifroy JJ, et al. Midodrine: a role in the management of neurocardiogenic syncope. Heart 1998;79:45-9. Randomised, placebo controlled, double blind study of midodrine in the treatment for reflex syncope showed significant benefits over placebo.