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Case Report | DOI: https://doi.org/10.31579/2639-4162/264
*Corresponding Author: K. Suresh, Family Physician & Public Health Consultant, Bengaluru, Karnataka 560022, India.
Citation: K. Suresh, (2025), Managing Syncope in Smaller Setting, J. General Medicine and Clinical Practice, 8(4); DOI:10.31579/2639-4162/264
Copyright: © 2025, K. Suresh. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 28 March 2025 | Accepted: 14 April 2025 | Published: 21 April 2025
Keywords: individual adaptation; interrelation; function; systemic structural trace
With all the variety of individual phenotypic adaptation, its development in higher animals is characterized by certain common features. There are two stages in the development of most adaptive reactions, namely: the initial stage of urgent but imperfect adaptation and the subsequent stage of perfect, long-term adaptation. The urgent stage of the adaptive reaction occurs immediately after the onset of the stimulus and, therefore, can be realized only on the basis of ready-made, previously formed physiological mechanisms. The obvious manifestations of urgent adaptation are the animal's flight in response to pain, an increase in heat production in response to cold, an increase in heat transfer in response to heat, an increase in pulmonary ventilation and minute volume of blood circulation in response to lack of oxygen. The most important feature of this stage of adaptation is that the body's activity proceeds at the limit of its physiological capabilities — with almost complete mobilization of the functional reserve — and does not fully provide the necessary adaptive effect. Thus, running of an unadapted animal or human occurs at near-maximum values of the minute volume of the heart and pulmonary ventilation, with maximum mobilization of the glycogen reserve in the liver; due to insufficiently rapid oxidation of pyruvate in muscle mitochondria, the level of lactate in the blood increases. This lacedemia limits the intensity of the load — the motor reaction can be neither fast enough nor long enough. Thus, adaptation is implemented "from the spot", but it turns out to be imperfect.
Syncope is a transient loss of consciousness and postural tone that occurs suddenly due to decreased cerebral blood flow, followed by spontaneous recovery. It affects 3% of males and 3.5% of females at some point in life [1,2]. As people get older incidence increases to affect up to 6% of people over age 75 years [2]. Vasovagal syncope (VVS), the commonest type of such a problem is defined as “the development of hypotension and bradycardia with the typical clinical manifestations of pallor, sweating and weakness and complete loss of consciousness for no more than 20 Seconds [4, 5]. VVS is frequent and benign, most people do not need special treatment, but repeated episodes and VVS in elderly can become a significant health and social challenge. India witnesses around 500,000 cases of Syncope each year of which one thirds are recurrent episodes and 70,000 are recurrent, infrequent unexplained Syncope [3]. Syncope in childhood is a common medical problem with an estimated incidence of 125.8 per 100.000 children and it is more frequent in females [1]. Orthostatic hypotension is a drop in blood pressure that occurs when a person has been standing for a while, or changes from a sitting to a standing position. Blood pools in the legs, preventing a normal amount of blood from being pumped to the brain. This brief drop in blood flow to the brain causes a person to faint. This more commonly occurs in older adults [5]. Presyncope is the prodrome of syncope in the absence of transient loss of consciousness in a person who has used countermeasures like sitting or lying down to avoid syncope. It is nothing but orthostasis without loss of consciousness or postural tone. [1,4]. Orthostasis" is the physiological response of the body’s autonomic nervous system, to maintain blood pressure when transitioning from a lying or sitting position to an upright position [6]. The condition can occur at any age, but a common clinical condition in the elderly with or without other medical issues. VVS or Transient Loss of Consciousness (TLOC) or is also a well-known phenomenon in dental/ maxillofacial surgery.
Syncope is associated with significant morbidity and risk of recurrence. Though Its pathophysiology remains to be fully elucidated, there appears to be a relation between trigemino-cardiac reflex and syncope, as seen under general anaesthesia when all sympathetic reflexes are blunted and under local anaesthesia during extractions of maxillary molars and mediate syncope [8]. Recurrent syncope causing a repeated reduction in the cerebral blood flow can predispose to progressive neurodegeneration, a decline in overall health and functionality [9]. Presyncope and syncope have a similar prognosis. Occasional dizziness or light-headedness may also be triggered by mild dehydration, low blood sugar or overheating, and standing up after sitting for a long time, with no cause for concern. If the symptoms of orthostatic hypotension, even for just a few seconds, occur frequently need medical consultation right away. This article is prompted by occasional attacks of Syncope by self and other cases managed or overseen & requisite literature search on pathophysiology & global management practices. It is necessary for all nations to take effective measures to address this problem given the commitment for healthy ageing life expectancy (HALE) challenge [13].
Following a quick cardiac consultation he was put on intravenous atropine 0.5 mg, repeated 5 more times, which helped to tide over the hemodynamic crisis.
Detailed evaluation of the case pointed out the cause as left carotid sinus syndrome (CSH), which is an exaggerated response to carotid sinus baroreceptor stimulation and results in dizziness or syncope from transient diminished cerebral perfusion.
In this case, mechanical deformation of the carotid sinus had led to an exaggerated response with bradycardia or vasodilatation, resulting in hypotension and syncope.
Today, vasovagal syncope is a common problem that has become a significant health and social challenge. Approximately 35% of people between 35 and 60 years of age have had at least one episode of VVS. By age 60, 42% of women and 32% of men experience vasovagal syncope at least once [5]. In a review of 12 studies with a sample size of 36,156 people, the global prevalence of vasovagal syncope was reported as 16.4 (95%CI: 6–37.5). The annual incidence of syncope is 5.7 episodes per 1000 individuals between 60 and 69 years and 11.1 episodes per 1000 individuals between 70 and 79 years, and after 80 years it rises to 19.5 per 1000 individuals [2] in Engaland. Syncope is a common in India, with incidence increasing with age, particularly after 70 years, and vasovagal syncope being the most frequent cause, especially in younger individuals. Syncope is broadly classified into four categories: reflex-mediated (neutrally mediated), cardiac, orthostatic, and neurological. In India Vasovagal Syncope (Neurocardiogenic) is the most common type of syncope, particularly in younger individuals followed by Cardiac causes which become more prevalent with age, including arrhythmias, structural heart problems, and ischemic heart disease, Orthostatic Hypotension is another common cause, especially in older adults, often related to medications or autonomic dysfunction. Some other causes include Neurological, endocrinological, & psychiatric disorders. Unexplained Syncope in which the cause remains unknown accounts for about 10% [13,4,5].
India specific epidemiological data is limited compared to other countries, but some specific considerations include i) Cultural & socioeconomic factors that influence the presentation and management. ii)The high prevalence of cardiovascular disease causes is a significant concern. More research is needed to better understand the epidemiology, causes, and management of syncope in the Indian population. Other non-Syncope causes of transient loss of consciousness include hypoglycaemia, seizure, concussion, psychogenic.
Vasovagal syncope is the most benign type of syncope, with an average prevalence of 22% in the general population, with a significant medical, social, and economic impact on the general population [7,9]. Approximately 35% of people between 35 and 60 years of age have had at least one episode of VVS. By age 60, 42% of women and 32% of men experience vasovagal syncope at least once [2]. The risk of vasovagal syncope is approximately between 3% of visits to the emergency room and 5% of outpatient visits to the hospitals [3].
Pathophysiology:
When a person stands, gravity causes blood to pool in the lower extremities, potentially leading to a drop in blood pressure and reduced blood flow to the brain. To counteract this, the body activates i) The sympathetic nervous system that constricts blood vessels and increases heart rate to maintain blood pressure ii) Muscle pumps and the non-uniform distensibility of blood vessels help to return blood to the heart. Most cases of Syncope are reflex mediated (60% -Vasovagal, Situational & Carotid sinus) followed by Orthostatic (15%- volume depletion, drug induced & autonomic failure) Arrythmias {10% either increased heart rate (VT, SVT) or decreased heart rate (Sinus Bradycardia, SSS, AVB)} and Cardiovascular or Structural (5%- Valvular, Vascular, obstructive or pump failure) defects. In 10
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