Syncope: Mechanisms and Management
Blair P. Grubb, MD. 416 pp. Armonk, NY: Futura Publishing Company, Inc; 1997. $89.00. ISBN 0-87993-6835.
The challenge of tackling the problem of syncope is not for the faint of heart. So diverse are the mechanisms, and often so transient is the presentation and so elusive the specific cause, that patients and medical care providers alike are left frustrated. Syncope exacts an enormous personal and economic toll and has potentially serious medical-legal implications. Thus, it is rather remarkable that to date there has been no truly comprehensive book on the subject. Enter Grubb, Olshansky, and 22 other contributors, who have succeeded admirably in their aim “to bring together in one volume a comprehensive yet usable source on syncope.”
The book reads easily, is well organized and referenced, and is liberally seasoned with useful tables, figures, and “real-life” cases from patients. The authors begin with overviews of evaluation, approach, and management, aided by “busy” but clinically helpful flow diagrams. The chapters on neurocardiogenic and dysautonomic syncope are first-rate. Bradyarrhythmias, tachyarrhythmias, and use of electrophysiological studies are each nicely treated separately. It was refreshing to read clinically focused chapters devoted to neurological causes of syncope, psychiatric disorders, and chronic fatigue syndrome, respectively. The chapters on carotid sinus hypersensitivity and miscellaneous causes of syncope are relatively short but useful. Pertinent discussions then follow of syncope in the child and adolescent, the athlete, and the elderly, respectively. Some of these areas are still controversial.
As anyone dealing with the problem of syncope knows, even the most intensive evaluations may not reveal a cause. Information on an earlier version of an implantable loop recorder is presented that suggests that this relatively new tool may help establish or exclude a specific arrhythmic etiology in some patients with recurrent unexplained syncope. The chapter on driving provides much practical information, even if the authors’ approach may not always concur with that of a previously published combined AHA/NASPE Medical Scientific Statement. The book ends with an interesting discussion of medical-legal aspects relating to syncope. The importance of history and physical examination in approaching the patient with syncope comes through clearly in different sections of this book.
The overwhelming excellence of this book makes its shortcomings relatively minor. A more in-depth treatment of baroreceptor physiology and pathophysiology would have been helpful. More attention to torsade de pointes, syncope in the setting of hypertrophic cardiomyopathy, adult congenital heart disease, and long-QT syndrome (admittedly a specialized area probably deserving its own book), and mention of microvolt T-wave alternans (possibly in regard to ventricular tachycardia) would have added to the completeness of the book. There are several errors in the references. Also, some useful and important references were not included (perhaps because the book had already gone to press), such as “Diagnosing Syncope” by M. Linzer et al (Ann Intern Med. 1997;126:989–996 and 1997;127:76–86) and the most recent “ACC/AHA Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices” by G. Gregoratos et al (J Am Coll Cardiol. 1998;31:1175–1209), although the previous guidelines are mentioned. The discussion on pacing as a therapeutic consideration for neurocardiogenic syncope is not well indexed.
Although this book does not always provide the reader with specific advice on how to manage certain clinical problems, it does supply most of the tools for formulating such a management decision by its multifaceted discussions in the many areas previously mentioned. Although specific treatment approaches are provided for some problems, others require more integrative processing by the reader.
In summary, this book deserves a prominent place on the shelf of anyone involved in caring for the patient presenting with syncope. Whether an emergency room physician, cardiologist, internist, or neurologist, the established practitioner or trainee should make a conscientious and “conscious” effort to read and own this book.
- Copyright © 1999 by American Heart Association