Syncope in the Elderly 응급의학과 R1 전종한 Clinical in geriatric medicine 23 (2007) Robert Hood, MD 응급의학과 R1 전종한

Introduction Definition Pathophysiology Epidemiology Etiology Diagnosis Treatment

Definition Result of generalized cerebral hypoperfusion Sudden, transient loss of consciousness and postural tone

Pathophysiology 양측 cerebral hemispheres 혹은 brainstem/midbrain reticular activating system 의 cerebral blood flow 감소 Cerebral blood flow => metabolic, chemical, auto-regulation 에 의해 결정되는MAP 와 cerebrovascular resistance

Epidemiology 응급실을 통한 전체 입원환자의 1~6 % 1.의 80% => 65세 이상 1.의 42% => unexplained syncope

Etiology

Neurocardiogenic syncope Most common Vasodepressor , vasovagal, reflex 노인환자의 30% : prodrome (-) C-fiber stretch receptor의 변화로 인한 hypercontractile, small ventricle => Bezold-Jarisch reflex

Orthostasis Orthostatic hypotension 나이가 들어감에 따라 심박동 보상기능감소 Systolic BP ↓ > 20 mmHg Diastolic BP ↓> 10 mmHg HR ↑ > 20 bpm Sitting => standing 3 분후 나이가 들어감에 따라 심박동 보상기능감소 Medication , postprandial state Antihypertensive(b-locker, diuretics)

Postprandial hypotension Indefinite etiology Relationship of syncope to meal

Carotid sinus hypersensitivity Bradycardia, asystole > 3 sec. Vasodepression 50세 이후 노화에 따라 증가 노인 > 65세 의 39% : syncope/dizziness (-/-)

Arrhythmia AV block sick sinus syndrome supraventicular arrhythmia Aging ⇒ AV block risk ↑ sick sinus syndrome Recurrent syncope, congestive failure supraventicular arrhythmia 단독 드뭄 Ischemic or nonischemic source⇒ EF↓

Atypical presentation Myocardial infarction Rarely Sx. 나이에 따라 증가 경향 Pulmonary embolism > 65세 : 24 % vs < 65세 : 3% Acute aortic dissection 5~10 % : syncope

Obstruction Aortic stenosis Mitral stenosis Atrial myxoma Inappropriated vasodilatation ⇒ ventricular pr.↑ Mitral stenosis Atrial myxoma

Alcohol & Illicits CDC 보고 : 노인에서 증가경향 2004 National Survey : > 60세 : 1.5% illicit drugs Syncope 의 multiple cause 중 하나

Diagnosis Careful history taking & physical exam. EKG Echocardiogram, tilt table testing, ambulatory monitoring Cardiac catheterization, neurological test 1+2 : most important, cheap, noninvasive 3+4 : very selected patients

Treatment 원인에 따라 다양 Bradyarrhythmia : pacemaker Vasodepressor syncope: volume expansion Midodrine (a-agonist)

감사합니다.