晕眩和晕厥:调查和处理

Neil R. Grubb, Nicholas A. Boon
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摘要

头晕和晕厥是普通人群,尤其是老年人的常见症状。晕厥可致残,导致身体损伤和丧失独立性。其原因可分为心律失常、心输出量机械减少、血管不适当扩张、神经源性和代谢性。心源性晕厥患者预后较差,除非病因得到迅速确认和治疗。诊断的关键是从病人或目击者那里获得关于症状的时间模式的明确病史,包括沉淀物,昏迷本身的描述和恢复速度。检查的重点是鉴别结构性心脏病和体位性低血压的征象。如果病史提示心脏诊断,超声心动图和动态心电图记录是有用的调查。对于间歇性症状提示心律失常的患者,植入式ECG环路记录仪越来越多地被使用。倾斜测试可用于调查可能的血管迷走神经性晕厥,脑电图或MRI头部扫描可用于识别昏厥的潜在神经局部原因。治疗晕厥的心血管原因可通过去除可逆性触发因素(如引起心动过缓或低血压的药物)或治疗基础疾病(如治疗症状性心动过缓的永久性起搏器,治疗主动脉瓣狭窄的主动脉瓣手术)。血管迷走神经性晕厥更难治疗,但可以通过避免可识别的诱因、使用药物和在某些情况下双室起搏来帮助治疗。
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Dizzy spells and syncope: investigation and management

Dizziness and syncope are common symptoms in the general population, especially the elderly. Syncope can be disabling and result in physical injury and loss of independance. Causes can be divided into arrhythmia, mechanical reduction in cardiac output, inappropriate vasodilatation, neurogenic and metabolic. Patients with cardiac syncope have a poor prognosis unless the cause is quickly identified and treated. The key to making a diagnosis is obtaining a clear history from the patient or a witness of the temporal pattern of symptoms including precipitants, a description of the blackout itself, and speed of recovery. Examination focuses on identification of signs of structural heart disease and postural hypotension. If the history suggests a cardiac diagnosis, echocardiography and ambulatory ECG recording are helpful investigations. For patients with intermittent symptoms suggesting arrhythmia, implantable ECG loop recorders are increasingly used. Tilt testing is used to investigate possible vasovagal syncope, and EEG or MRI head scan can be used to identify potential neurologocal causes of blackouts.

Cardiovascular causes of syncope are treated by removal of reversible triggers (e.g. drugs that cause bradycardia or hypotension) or by treatment of the underlying condition (e.g. permanent pacemaker for symptomatic bradycardia, aortic valve surgery for aortic stenosis). Vasovagal syncope is more difficult to treat but can be helped by avoiding identifiable triggers, use of medication and in some cases dual chamber pacing.

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