Differential Diagnosis and Treatment of Syncope 서울성모병원순환기내과 김성환
Not syncope, it s dizziness or presyncope
Syncope is a loss of consciousness
M/46, 실신 평소건강 3일전직장동료와저녁회식하면서, 소주 3~4잔먹은후, 화장실에서소변보는도중의식을잃고쓰러짐. 1분정도후에의식회복. 넘어지면서머리에찰과상.
F/23, 실신 중학생시절부터운동장에오래서있으면메스꺼움, 배아픔과함께심한어지럼증을느끼곤했음. 3일전출근하는혼잡스러운지하철안에서, 메스꺼움, 배아픔과함께의식잃고쓰러짐. 주변사람의말에의하면, 의식소실동안특별한움직임은없었다고함. 2~3분후에특이한후유증상없이의식회복.
M/25, 실신 큰아버지 30 대에자다가돌연사 평소건강 1일전저녁식사후앉아서 TV 보던중, 갑자기의식잃고쓰러짐. 30초정도후에특별한후유증없이의식회복.
F/70, 실신 고혈압, 당뇨로약물복용중 평소간간히두근거리는증상있었음. 1주전걸어가다가, 갑자기두근거리는증상 1분정도있은뒤, 심한어지럼증느끼며의식소실. 곧바로회복됨.
Male/15, 실신 3 년전부터걸어가는도중갑작스런의식소실, 1 분정도후에깨어남. 1 달에 1~2 번정도증상반복, 최근빈도잦아짐.
실신이란? 뇌혈류감소에의한, 일시적인의식소실 (transient loss of consciousness) Transient LOC Non- traumatic Syncope Seizure Traumatic psychogenic
실신 (syncope) 과발작 (seizure) 의감별 실신 (syncope) 발작 (seizure) 기전일시적인뇌혈류감소뇌안에서생긴부정맥 전구증상빈도 ~50 % 없음 환각 실신후반 대개발작전 자세 이완혹은경직 경직 움직임 ~80 %, < 30 s 불규칙, 다발성 대부분, 1~2 min, 규칙적, 전신성 눈간헐적으로돌아감흔히돌아감 혀깨물기드뭄흔함 혼돈 (postictal confusion) < 30 s 2~20 min
실신의교과서적인분류 1) Neurally mediated syncope Vasovagal: fear, pain Situational: micturition, cough, sneeze, GI stimulation, exercise, diet Carotid sinus 2) Orthostatic hypotension Primary, secondary (DM, amyloidosis, uremia, spinal cord injury), drug, volume depletion 3) Cardiac syncope Bradycardia, tachycardia (VT/VF ), valvular disease, AMI, hypertrophic cardiomyopathy, pulmonary embolism
일시적인의식소실 의개념적인분류 Brain arrhythmia Arrhythmia (seizure) Non- (malignant) Cardiac arrhythmia (brady or VF/VT) Transient LOC traumatic Traumatic Vascular reflex (benign) Neurally mediated syncope Orthostatic hypotension
신경매개성실신 (neutrally mediated syncope) 과심장성실신 (cardiac syncope) 의감별 전구증상 신경매개성실신 (neutrally mediated syncope) 오심, 구토, 복통, 배변감, 전신위약, 어지럼증 심장성실신 (cardiac syncope) 없거나흉부불편감 실신후증상전신위약감없거나이차적인외상증상 상황 화장실, 지하철, 혼잡공간, 음주후, 일어선직후 특이상황없음 기억실신직전상황기억함기억못함 환자특성젊은층노인, 심장질환
Age of first syncope Neurally mediated syncope Cardiac syncope Ganzeboom et al. Am J Cardiol 2003
Age of first syncope in alcoholics Neurally mediated syncope 떡실신 Cardiac syncope
실신의흔한원인 진찰장소 Setting Neurally mediated syncope (%) Orthostatic (%) Cardiac (%) Other (%) Unexplained (%) 일반인구 21 9.4 9.5 9 37 응급실 40 5 10 15 30 외래 60 2.5 20 2.5 15 ESC guildelines 2009, Euro Heart J
Syncope 의흔한원인 연령별 Age Neurally mediated syncope (%) Orthostatic (%) Cardiac (%) Other (%) Unexplaned (%) < 40 51 2.5 1.1 18 27 40~60 37 6 3 19 34 > 75 36 30 16 9 ESC guildelines 2009, Euro Heart J
예후는? 가장중요한것은 cardiac syncope 여부를확인하는것!!! 병력청취 : 자세, 활동, 전구 / 동반 / 직후증상 심혈관질환위험인자 : 나이, 흡연, 동반질환, 가족력 ECG 필요하면, echo, treadmil test, heart MR
진단을위한검사 1. Neurally mediated syncope or orthostatic hypotension - 굳이검사로확인하자면, Tilt test 2. Cardiac syncope - ECG, Echo, treadmil test
Tilt test 에대한불편한진실
Tilt test 시행방법 기립에대한 neurally mediated syncope 혹은 orthostatic hypotension 의반응을재현하기위함 병원마다다양한 protocol 관상동맥질환이없고, 심각한구조적심장질환이없어야함 (ex. aortic stenosis, LV dysfunction )
어떤검사의유용성 민감도 (sensitivity): 실제병이있을때, 검사에나올확률 ex.) 발작성심방세동에대한 ECG 1 회검사의민감도는낮다. 좌각차단에대한 ECG 의민감도는높다. 특이도 (specificity): 검사양성일때실제병이있을확률 ex.) 발작성심방세동에대한 ECG 의특이도는높다. 대장암에대한분변검사의특이도는낮다.
Tilt 검사의유용성 민감도 : 26~80% -> 병력청취에서 neurally mediated syncope 가의심되면, 설령 Tilt 정상 이라도가장가능성이높은진단은 neurally mediated syncope 특이도 : 90% (without drug), 50% (with drug) -> 정상인도 isoproterenol 주면 50% 에서양성나옴.
Tilt 검사가특히불필요한경우 병력청취로 neurally mediated syncope 가의심 되는환자에게는필요없음. 치료효과판정을위해서도필요없음.
병력청취를해봐서, Vascular reflex (neurally mediated syncope or orthostatic hypotension) 의가능성이, 높으면 -> Tilt 결과에상관없이 vascular reflex 일가능성이가장많음. 낮으면 -> cardiac syncope 를확인하기위한검사가필요함 (bradycardia, VT/VF) => 결국 Tilt 검사는대부분의환자에서유용성이떨어진다.
Tilt 검사유의사항 대부분안전하지만, Isoproterenol 금기 : 관상동맥질환, 동기능부전증후군, 심한고혈압, 좌심실유출로폐쇄, 대동맥판막협착증. 두통 (nitroglycerine), 심방세동
일시적인의식소실 의개념적인분류 Brain arrhythmia Arrhythmia (seizure) Non- (malignant) Cardiac arrhythmia (brady or VF/VT) Transient LOC traumatic Traumatic Vascular reflex (benign) Neurally mediated syncope Orthostatic hypotension
Cardiac syncope 에대한검사 1) Bradycardia 증상있을때심전도 ECG, 24시간 Holter, event recording, 하트콜, implantable loop recorder 2) VT/VF Ventricle 의이상유무 Echo, Treadmil, coronary CT, heart MR, CAG
Those who suffer from frequent and severe fainting often die suddenly - Hippocrates
돌연심장사의역학 한국에서만매년 2 만명 병원외발생만포함 십만명당 41 명 미국에서는매년 25 만 ~ 30 만명 십만명당 53 명
돌연심장사의원인 VT/VF 가장흔한직접적원인 생존율 : 1 분에 10 % 씩감소 기타원인 뇌졸중, 폐색전증, 대동맥파열
VT/VF 의분류 Monomorphic VT Idiopathic VT Scar-related VT - Polymorphic VT - VF Scar-related Inherited primary arrhythmia syndrome
Monomorphic VT 의분류 Scar-related Idiopathic Etiology ICM, DCM, HCM, ARVD, sarcoidosis, congenital, surgical scar. outflow tract VT fascicular VT Prognosis as underling disease benign Treatment ICD ± ablation amiodarone, sotalol verapamil, beta blocker ablation
기전, 예후, 치료방침결정 Idiopathic PVC/VT PSVT
VT/VF 의분류 Monomorphic VT Idiopathic VT Scar-related VT - Polymorphic VT - VF Scar-related Inherited primary arrhythmia syndrome
Polymorphic VT/VF (= 돌연심장사 ) 관련질환 구조적심질환 (=ventricle scar) 심근경색 (>80%) 확장성심근증 (DCMP), 비후성심근증 (HCMP), 부정맥유발우심실이형성증 (arrhythmogenic RV dysplasia), surgical scar Inherited primary arrhythmia syndrome Long/Short QT 증후군 브루가다증후군 Catecholaminergic polymorphic VT 조기재분극증후군 (Early repolarization syndrome) 특발성심실세동 (Idiopathic ventricular fibrillation)
심근경색후사망률과 EF 와의관계 mortality after MI The multicenter Postinfarction Research Group, NEJM 1983
심부전환자의사망원인 VT/VF : about 50%! The mortality in HF is bimodal Severe HF Pump failure SCD : 10~40% Mild symptom Ventricular arrhythmia SCD: > 50% McMurray et al, NEJM 2010
치료방법 항부정맥제 disappointing except beta blocker ICD numerous evidences!
ICD 효과를입증한연구들 Trial Publish N Patients Age (y) EF (%) FU (m) RR (%) reduction MADIT NEJM 96 196 ICM, EF 35, NSVT, EPS+ 63 26 27 54 MADIT-II NEJM 02 1232 ICM, EF 30 64 23 20 31 COMPANION NEJM 04 1520 EF 35, QRS>120 67 21 14 40 SCD-HeFT NEJM 05 2521 EF 35 60 25 46 23
MADIT II trial (8 yr FU), MI with EF<30% HR 0.66 (0.56-0.78) Goldenberg et al, Circulation 2010
돌연심장사관련질환 구조적심질환 (=ventricle scar) 심근경색 (>80%) 확장성심근증 (DCMP), 비후성심근증 (HCMP), 부정맥유발우심실이형성증 (arrhythmogenic RV dysplasia), surgical scar Inherited primary arrhythmia syndrome Long/Short QT 증후군 브루가다증후군 Catecholaminergic polymorphic VT 조기재분극증후군 (Early repolarization syndrome) 특발성심실세동 (Idiopathic ventricular fibrillation)
Cardiac syncope 의심환자에서반드시감별해야할질환 구조적심질환 (=ventricle scar) 심근경색 (>80%) 확장성심근증 (DCMP), 비후성심근증 (HCMP), 부정맥유발우심실이 형성증 (arrhythmogenic RV dysplasia), surgical scar Inherited primary arrhythmia syndrome Long/Short QT 증후군 브루가다증후군 Catecholaminergic polymorphic VT 조기재분극증후군 (Early repolarization syndrome) 특발성심실세동 (Idiopathic ventricular fibrillation)
Cardiac syncope 의심환자에서반드시감별해야할질환 구조적심질환 (=ventricle scar) 심근경색 (>80%) Echo, TMT, coronary CT, CAG, heart MR 확장성심근증 (DCMP), 비후성심근증 (HCMP), 부정맥유발우심실이 형성증 (arrhythmogenic RV dysplasia), surgical scar Inherited primary arrhythmia syndrome Long/Short QT 증후군 ECG, TMT 브루가다증후군 Catecholaminergic polymorphic VT 조기재분극증후군 (Early repolarization syndrome) 특발성심실세동 (Idiopathic ventricular fibrillation)
치료 1. Cardiac syncope - bradycardia: 인공심박동기 - VT/VF: 삽입형제세동기
치료 2. Neurally mediated or orthostatic hypotension - 유발인자회피 : 혼잡지역, 탈수 - 전구증상기억 - 실신억제 maneuvers: isometric physical counterpressure manuver ( 다리꼬기, 양손쥐기, 팔당기기 ) - 효과가입증된약물은없다.
Take hospital messages (1) 실신환자의진단을위해서는병력청취를통해, neurally mediated or orthostatic hypotension 인지, cardiac syncope 인지구분하는것이가장중요하다. 전구증상, 쓰러진상황, 환자연령 Syncope Neurally mediated or orthostatic hypotension 의식소실 Cardiac syncope Seizure
Take hospital messages (2) 실신환자에게 Tilt test 를 routine 으로시행하는 것은바람직하지못하다. Cardiac syncope 가의심된다면, 심실이상유무 (scar-related) 를확인하기위해검사를시행해야 한다.
부정맥관련환자설명자료들 http:// 부정맥.com/ http://blog.naver.com/cmcep https://mobile.twitter.com/cmcheartrhythm