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cardio.neurally-mediated-reflex-syncope.v1

Neurally-Mediated Reflex Syncope (vasovagal / situational / carotid sinus)

cardiologyacutechronicadultacuteoutpatienttransition
Start encounter →Print handoutPRODUCTION

Reflex (neurally-mediated) syncope dossier — vasovagal, situational, carotid sinus subtypes ED stratification with Canadian Syncope Risk Score Step 1: education + counterpressure maneuvers + hydration + salt loading Step 2: midodrine 5–10 mg TID + fludrocortisone 0.1–0.2 mg daily Step 3: permanent pacemaker for cardioinhibitory subtype age >40 + recurrent syncope (BIOSync) Step 4: combination, paroxetine, atomoxetine, pyridostigmine for refractory Severity triggers cover high-risk ECG, exertional / supine syncope, family SCD, cardioinhibitory pacing eligibility, supine HTN on midodrine, fludrocortisone hypokalemia Sibling differentiation against arrhythmic / orthostatic syncope PRODUCTION blockers: (1) RxCUIs not yet populated, (2) manifest stub blank, (3) registry import not added per instructions, (4) sibling cardio.htn.core.v1 already exists; cardio.afib.core.v1 already exists

Entry points (5)

  • symptom
    Transient loss of consciousness with rapid spontaneous recovery (ESC 2018 Brignole — definition of syncope)
    transient_loss_of_consciousness
  • symptom
    Prodrome of warmth, nausea, diaphoresis, blurred vision, lightheadedness (ESC 2018 — classic vasovagal prodrome)
    prodromal_features
  • history
    Trigger — emotional stress, prolonged standing, micturition, defecation, cough, swallowing (ACC/AHA/HRS 2017 — situational subtypes)
    trigger_situational
  • history
    Recurrent reflex syncope despite lifestyle measures (ESC 2018 — pharmacotherapy/pacing indication)
    recurrent_syncope
  • symptom
    Syncope with neck shaving, tight collar, head turning — carotid sinus syndrome (ESC 2018 Brignole)
    carotid_sinus_pressure_syncope

Required inputs (19)

  • agerequired
    demographic • used at CONTEXT
    Risk stratification + pacing eligibility (BIOSync >40) (ACC/AHA 2022)
  • sbprequired
    vital • used at CONTEXT
    Orthostatic vitals + supine vs standing pattern (ACC/AHA/HRS 2017)
  • hrrequired
    vital • used at CONTEXT
    Bradycardia at event, baseline HR pattern (ESC 2018 Brignole)
  • orthostatic_vitalsrequired
    vital • used at INITIAL_WORKUP
    Drop ≥20 SBP / ≥10 DBP / new symptoms within 3 min standing — orthostatic vs reflex pattern (ACC/AHA/HRS 2017; ESC 2018)
  • triggers_and_prodromerequired
    history • used at CONTEXT
    Classic vasovagal pattern vs cardiac arrhythmic syncope — no prodrome, exertional, supine (ESC 2018 Table 4)
  • family_history_sudden_death_or_arrhythmiarequired
    history • used at CONTEXT
    Inherited arrhythmia syndromes — long QT, Brugada, HCM, ARVC (ACC/AHA/HRS 2017 high-risk features)
  • structural_heart_diseaserequired
    history • used at CONTEXT
    Reduces probability of benign reflex etiology; raises Canadian Syncope Rule risk (Thiruganasambandamoorthy JAMA 2016)
  • injury_during_syncope
    history • used at CONTEXT
    Suggests absent prodrome — cardiac etiology more likely (ESC 2018 Brignole)
  • current_medsrequired
    medication • used at CONTEXT
    Antihypertensives, diuretics, alpha-blockers, vasodilators, QT-prolonging agents (ACC/AHA/HRS 2017)
  • cbc
    lab • used at INITIAL_WORKUP
    Anemia / GI bleed mimic (ACC/AHA/HRS 2017 — selective labs)
  • bmp
    lab • used at INITIAL_WORKUP
    Volume / electrolyte status; QT-affecting K+ / Mg (ACC/AHA/HRS 2017)
  • glucose
    lab • used at INITIAL_WORKUP
    Hypoglycemia mimic (ACC/AHA/HRS 2017)
  • troponin
    lab • used at INITIAL_WORKUP
    Exclude ACS / myocardial injury; selective use (ACC/AHA/HRS 2017)
  • bnp
    lab • used at INITIAL_WORKUP
    HF mimic (ACC/AHA/HRS 2017 — selective)
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Mandatory for any syncope — long QT, Brugada, WPW, AV block, ischemic changes, HCM patterns (ESC 2018 Class I; ACC/AHA/HRS 2017 Class I)
  • echo
    imaging • used at BRANCHING_WORKUP
    When structural heart disease suspected by history / exam / ECG (ACC/AHA/HRS 2017 Class IIa)
  • tilt_table_test
    imaging • used at BRANCHING_WORKUP
    Tilt-table reproduces vasovagal in equivocal cases — not routine (ESC 2018 Class IIb)
  • carotid_sinus_massage
    imaging • used at BRANCHING_WORKUP
    Diagnose carotid sinus syndrome — pause >3 s OR SBP drop >50 mmHg (ESC 2018 Brignole)
  • implantable_loop_recorder
    imaging • used at BRANCHING_WORKUP
    Recurrent unexplained syncope after initial workup (ESC 2018 Class I for recurrent unexplained)

12-phase flow (12)

  1. 1FRAME
    Confirm syncope — transient LOC due to global cerebral hypoperfusion with rapid recovery, no postictal (ESC 2018 Brignole — definition) vs seizure / metabolic / pre-syncope
    advance: Syncope confirmed and broad differential narrowed
  2. 2ENTRY
    Triggered by transient LOC presenting to ED or clinic (ACC/AHA/HRS 2017)
    inputs: age
    advance: Entry symptom present with witness or self-account
  3. 3CONTEXT
    Triggers, prodrome, position at onset, posture, exertional vs not, recurrence pattern, family history of SCD, structural heart disease, medications (ESC 2018 Table 4; ACC/AHA/HRS 2017)
    inputs: triggers_and_prodrome, family_history_sudden_death_or_arrhythmia, structural_heart_disease, injury_during_syncope, current_meds, sbp, hr
    advance: Reflex pattern vs alternative pattern established
  4. 4RED_FLAGS
    Exertional, supine, lack of prodrome, family history SCD, palpitations preceding, abnormal ECG — high-risk Canadian Syncope features (Thiruganasambandamoorthy JAMA 2016; ESC 2018)
    inputs: ecg, sbp, hr
    advance: High-risk features absent OR cardiac workup escalated
  5. 5INITIAL_WORKUP
    ECG mandatory (ESC 2018 Class I); orthostatic vitals; CBC + BMP + glucose; pregnancy test where relevant; troponin / BNP / lactate selective (ACC/AHA/HRS 2017)
    inputs: ecg, orthostatic_vitals, cbc, bmp, glucose
    advance: Baseline workup negative for high-risk features
  6. 6BRANCHING_WORKUP
    Echo if structural HD suspected (ACC/AHA/HRS 2017 Class IIa); tilt-table for equivocal vasovagal (ESC 2018 Class IIb); carotid sinus massage age >40 (ESC 2018); ILR for recurrent unexplained (ESC 2018 Class I); EP study if structural HD + arrhythmia suspicion
    inputs: echo, tilt_table_test, carotid_sinus_massage, implantable_loop_recorder
    advance: Targeted tests sent or deferred per pre-test probability
  7. 7DIFFERENTIAL
    Reflex (vasovagal / situational / carotid sinus) vs orthostatic vs cardiac arrhythmic vs structural cardiac vs neurologic — per ESC 2018 classification
    advance: Working etiology assigned
  8. 8RISK_STRATIFICATION
    Canadian Syncope Risk Score — 30-day SAE risk (Thiruganasambandamoorthy JAMA 2016); ESC short-term risk; cardioinhibitory vs vasodepressor vs mixed subtype (ESC 2018)
    inputs: ecg
    advance: Risk score assigned and disposition implied
  9. 9TREATMENT
    Education + counterpressure maneuvers (ESC 2018 Class I); midodrine 5–10 mg TID (POST IV); fludrocortisone 0.1–0.2 mg daily (POST II NEJM 2013); permanent pacemaker for cardioinhibitory age >40 + recurrent (BIOSync NEJM 2021 — Class IIa ESC); paroxetine for refractory; deprescribe offending meds
    inputs: current_meds
    advance: Stepwise plan documented
  10. 10DISPOSITION
    Discharge if Canadian Syncope low-risk; observation 4–6 h if intermediate; admit if high-risk (Thiruganasambandamoorthy JAMA 2016; ACC/AHA/HRS 2017)
    advance: Disposition decided
  11. 11MONITORING
    Outpatient: symptom diary, BP log, recurrence frequency, fluid + salt adherence (ESC 2018); pacemaker interrogation if implanted; tilt-table for protocol assessment
    advance: Trajectory monitored and plan refined
  12. 12FOLLOWUP
    Driving restrictions per local rules (ESC 2018 §6.4); occupational counselling; reassessment of BP-lowering meds; safety planning for warning signs + counterpressure maneuvers (ACC/AHA/HRS 2017)
    advance: Follow-up plan + safety + driving / occupational guidance documented