今日の臨床サポート

失神

著者: 武村克哉 琉球大学病院 地域・国際医療部

監修: 徳田安春 一般社団法人 群星沖縄臨床研修センター

著者校正/監修レビュー済:2020/12/03
参考ガイドライン:
  1. ヨーロッパ心臓病学会(ESC):2018 ESC Guideline for the diagnosis and management of syncope
  1. 日本循環器学会:失神の診断・治療ガイドライン(2012年改訂版)
患者向け説明資料

概要・推奨   

診断:初期評価
  1. 最初に、(1)そのイベントは一過性意識消失(T-LOC: Transient loss of consciousness)か、(2)T-LOCであれば、失神あるいは非失神か、(3)失神が疑われる場合、明らかな原因診断はあるか、(4)心血管イベントまたは心血管死の高リスクを示唆する所見はあるか、を考える。
  1. 救急部門でのT-LOCの評価では、まず、(1)重大な基礎疾患はあるか、(2)原因が明らかでない場合、重篤な転帰のリスクは何か、(3)入院させる必要があるか、を考える。
  1. すべての失神患者で、詳細な病歴聴取、身体診察(立位での血圧測定を含む)、心電図検査を行う(推奨度1)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
武村克哉 : 特に申告事項無し[2021年]
監修:徳田安春 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 失神とは、「一過性の意識消失の結果、姿勢が保持できなくなり、かつ自然に、また完全に意識の回復がみられること」と定義される{失神の診断・治療ガイドライン(2012年改訂版)}。
  1. 失神は日常診療でよく遭遇する症状であり、疫学的にも全人口の1/3が経験するといわれている。
  1. その病態生理は、「脳全体の一過性低灌流」である。原因は多岐にわたり特定できない場合もあるが、具体的な原因は神経反射性(59%)、心疾患(23%、特に不整脈)、その他に分けられる[1]。致命的疾患の前兆として失神が観察されることもあるが、大抵の原因は自然消退するものである。
  1. 意識障害という点で心肺停止と区別される必要がある。ただし心原性の失神は心肺停止に移行する可能性もあり(24%)[2]、 注意が必要である。
  1. 失神に続発する外傷(転倒などによる)が懸念されるため、患者への説明が重要である。
問診・診察のポイント  
失神とその他の意識消失との鑑別:
  1. 失神は脳全体の一過性低灌流によるものであり、それ以外の意識消失(脳全体の低灌流を伴わないもの:てんかんや中毒、代謝系障害[低血糖、低酸素血症、高炭酸ガス血症]、椎骨脳底動脈の解離・塞栓・血栓)や意識障害を伴わない失神に近い症状を出す病態(カタプレキシー、転倒、脳虚血)とは区別される[3]
  1. てんかん発作と失神の鑑別についてはさまざまな点が指摘されているが[4]、特に重要なのは、てんかんでは意識消失からの回復がゆっくりで完全に元の意識に戻るという回復相(postictal state)があり、失神では回復が急速かつ完全であるということである。また、けいれんと失神の鑑別に舌咬傷(感度45%、特異度97%)、頭位変換(感度43%、特異度97%)、postictal confusion(感度94%、特異度69%)が特に有用である。これらを認める患者では特にけいれんを疑い、脳波図でてんかん発作を診断、治療する。
  1. また、以下の4つの質問の答えがYesであった場合は失神の可能性が高く、3つ以下であった場合は上記それ以外の意識消失の原因を探索する必要がある[3]
  1. 1)意識消失が完全であったか

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文献 

著者: P Alboni, M Brignole, C Menozzi, A Raviele, A Del Rosso, M Dinelli, A Solano, N Bottoni
雑誌名: J Am Coll Cardiol. 2001 Jun 1;37(7):1921-8.
Abstract/Text OBJECTIVES: We sought to establish what historical findings are predictive of the cause of syncope.
BACKGROUND: The clinical features of the various types of syncope have not been systematically investigated.
METHODS: Three hundred forty-one patients with syncope were prospectively evaluated. Each patient was interviewed using a standard questionnaire. A cause of syncope was assigned using standardized diagnostic criteria.
RESULTS: A cardiac cause of syncope was established in 23% of the patients, a neurally mediated cause in 58% and a neurologic or psychiatric cause in 1%, and in the remaining 18%, the cause of syncope remained unexplained. In a preliminary analysis including age, gender and the presence of suspected or certain heart disease after the initial evaluation, only heart disease was an independent predictor of a cardiac cause of syncope (odds ratio 16, p = 0.00001), with a sensitivity of 95% and a specificity of 45%. In contrast, the absence of heart disease allowed us to exclude a cardiac cause of syncope in 97% of the patients. In patients with certain or suspected heart disease, the most specific predictors of a cardiac cause were syncope in the supine position or during effort, blurred vision and convulsive syncope. Significant and specific predictors of a neurally mediated cause were time between the first and last syncopal episode >4 years, abdominal discomfort before the loss of consciousness and nausea and diaphoresis during the recovery phase. In the patients without heart disease, palpitation was the only significant predictor of a cardiac cause.
CONCLUSIONS: The presence of suspected or certain heart disease after the initial evaluation is a strong predictor of a cardiac cause of syncope. A few historical findings are useful to predict cardiac and neurally mediated syncope in patients with and without heart disease.

PMID 11401133  J Am Coll Cardiol. 2001 Jun 1;37(7):1921-8.
著者: W N Kapoor
雑誌名: Medicine (Baltimore). 1990 May;69(3):160-75.
Abstract/Text We studied 433 patients with syncope to derive insights into the diagnostic evaluation and outcome of patients with this common problem. This study shows that the etiology of syncope was not found in approximately 41% of patients. When a cause of syncope was determined, it was most frequently established on the basis of initial history, physical examination and an electrocardiogram (EKG). Furthermore, many of the other entities (e.g., aortic stenosis, subclavian steal) were suggested by findings on the history and physical examinations that required directed diagnostic testing. Initial EKG was abnormal in 50% of patients but led to a cause of syncope infrequently (less than 7%). Prolonged electrocardiographic monitoring, which has assumed a central role in the evaluation of syncope, led to a specific cause in only 22% of patients. Other tests were less often helpful in assigning a cause of syncope. At 5 years, the mortality of 50.5% in patients with a cardiac cause of syncope was significantly higher than the 30% mortality in patients with a noncardiac cause or 24.1% in patients with an unknown cause. At 5 years, a mortality of 50.5% in patients with a cardiac cause of syncope was noted. There were 54 actual deaths in this group as compared to 10.7 expected deaths based on 1980-86 mortality data from Allegheny County, PA (standardized mortality ratio = 5.02). At 5 years, a 33.1% incidence of sudden death was noted in patients with cardiac cause of syncope, as compared with 4.9% in patients with a noncardiac cause and 8.5% in patients with an unknown cause. Mortality and sudden death remained significant for the first 3 years after which the survival curves were parallel. A cardiac cause of syncope was an independent predictor of sudden death and mortality. Recurrences were common but were not associated with an increased risk of mortality or sudden death. Major vascular events were also more frequent in patients with cardiac causes of syncope. The results of this study will be helpful in designing future studies to evaluate the usefulness of newer diagnostic techniques. Furthermore, short- and long-term outcome data will be useful in planning intervention strategies in these patients.

PMID 2189056  Medicine (Baltimore). 1990 May;69(3):160-75.
著者: Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology (ESC), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA), Heart Rhythm Society (HRS), Angel Moya, Richard Sutton, Fabrizio Ammirati, Jean-Jacques Blanc, Michele Brignole, Johannes B Dahm, Jean-Claude Deharo, Jacek Gajek, Knut Gjesdal, Andrew Krahn, Martial Massin, Mauro Pepi, Thomas Pezawas, Ricardo Ruiz Granell, Francois Sarasin, Andrea Ungar, J Gert van Dijk, Edmond P Walma, Wouter Wieling
雑誌名: Eur Heart J. 2009 Nov;30(21):2631-71. doi: 10.1093/eurheartj/ehp298. Epub 2009 Aug 27.
Abstract/Text
PMID 19713422  Eur Heart J. 2009 Nov;30(21):2631-71. doi: 10.1093/eurh・・・
著者: Warren T Blume
雑誌名: CMAJ. 2003 Feb 18;168(4):441-8.
Abstract/Text This article concisely describes the more common epilepsy conditions and will enable physicians to efficiently evaluate and manage these disorders. Salient aspects of the history and examination, together with electroencephalography, will usually determine the epilepsy syndrome (category), forming the basis for any further investigation and possible antiepileptic therapy. Imaging may be required in some circumstances.

PMID 12591787  CMAJ. 2003 Feb 18;168(4):441-8.
著者: W Grimm, M Degenhardt, J Hoffman, V Menz, A Wirths, B Maisch
雑誌名: Eur Heart J. 1997 Sep;18(9):1465-9.
Abstract/Text BACKGROUND: Head-up tilt testing is widely used in the evaluation of patients with suspected neurally mediated syncope. Although it remains unclear which patients require medical therapy to prevent recurrent syncope, most centres initiate empiric medical therapy in all patients in whom neurally mediated syncope has been diagnosed. To determine the natural history of this condition, we followed 80 untreated patients.
METHODS: All 80 study patients fulfilled the following inclusion criteria: (1) > or = 1 syncope in the upright position, (2) absence of structural heart disease, (3) unremarkable work-up for other known causes of syncope. Thirty-nine patients had a history of one episode of syncope (group A) and 41 > or = 2 episodes of syncope (group B). Head-up tilting was performed in all patients at 60 degrees for a maximum of 45 min without medical provocation ('Westminster Protocol').
RESULTS: Suspected neurally mediated syncope could be reproduced by tilt testing in four of 39 patients from group A vs 10 of 41 patients from group B (10% vs 24%, P = 0.1). Independent of the result of head-up tilt testing, all patients were prospectively followed without medical therapy. During 23 +/- 8 months follow-up, syncope recurred in four of 39 group A patients vs 22 of 41 group B patients (10% vs 54%, P < 0.05). The incidence of syncope during follow-up was not significantly different between patients with and without positive baseline tilt test (43% vs 30%, P = ns).
CONCLUSIONS: (1) 90% of patients with a single episode of syncope remain free of recurrent syncope without medical therapy irrespective of the result of tilt testing. (2) About half of patients with a history of > or = 2 syncopal episodes have recurrent syncope and, thus, may be appropriate candidates for prophylactic medical therapy. (3) Although head-up tilt testing at 60 degrees for up to 45 min does not appear to be useful to predict recurrent syncope in untreated patients, it is still a useful test in its evaluation.

PMID 9458453  Eur Heart J. 1997 Sep;18(9):1465-9.
著者: A D Krahn, G J Klein, R Yee, A C Skanes, REVEAL Investigators
雑誌名: Am Heart J. 2001 May;141(5):817-21. doi: 10.1067/mhj.2001.114196.
Abstract/Text BACKGROUND: The purpose of this study was to assess the diagnostic value of recording the cardiac rhythm during presyncope in patients undergoing monitoring for undiagnosed syncope.
METHODS AND RESULTS: Eighty-five patients (age, 59 +/- 18 years; 44 men, 41 women) with recurrent unexplained syncope underwent prolonged monitoring with an implantable loop recorder. Patients were examined for syncope, which was either recurrent or associated with at least 2 presyncopal episodes. Patients had a mean of 5.1 +/- 5.5 syncopal episodes in the previous 12 months, and 70% of patients had symptoms for >2 years. Sixty-two (73%) patients had recurrent symptoms during a 12-month follow-up period. Of 150 recurrent events captured by the implantable loop recorder, there were 38 (25%) episodes of syncope and 112 (75%) episodes of presyncope. Syncope alone recurred in 12 patients, presyncope in 25, and both in 16. An arrhythmia was present in 64% of syncopal events (bradycardia in 16, tachycardia in 2) versus 25% for presyncopal events (bradycardia in 7, tachycardia in 3, P =.001). An arrhythmia was detected in 9 (56%) of the 16 patients with both syncope and presyncope, which was present in all recorded episodes of syncope compared with 6 of 9 presyncopal episodes. Patient-related failure to freeze the device after symptoms occurred in 21 (36%) of 59 syncopal events compared with 15 (12%) of 127 presyncopal events (P =.0001).
CONCLUSIONS: Syncope is more likely to be associated with an arrhythmia than is presyncope in patients undergoing extended monitoring. Presyncope is a nonspecific end point that is frequently associated with sinus rhythm. Patients undergoing extended monitoring for syncope should continue to be monitored after an episode of presyncope unless an arrhythmia is detected.

PMID 11320372  Am Heart J. 2001 May;141(5):817-21. doi: 10.1067/mhj.20・・・
著者: Michael Klompas
雑誌名: JAMA. 2002 May 1;287(17):2262-72.
Abstract/Text CONTEXT: The diagnosis of acute thoracic aortic dissection is difficult to make and often missed.
OBJECTIVE: To review the accuracy of clinical history taking, physical examination, and plain chest radiograph in the diagnosis of acute thoracic aortic dissection.
DATA SOURCES: A comprehensive review of the English-language literature was conducted using MEDLINE for the years 1966 through 2000. Additional sources were identified from the references of retrieved articles.
STUDY SELECTION: The search revealed 274 potential sources, which were reviewed for pertinence and quality. Articles included were original investigations describing the clinical findings for 18 or more consecutive patients with confirmed thoracic aortic dissection. Twenty-one studies were identified that met selection criteria.
DATA EXTRACTION: Critical appraisal and data extraction were performed by the author.
DATA SYNTHESIS: Most patients with thoracic aortic dissection have severe pain (pooled sensitivity, 90%) of sudden onset (sensitivity, 84%). The absence of sudden pain onset lowers the likelihood of dissection (negative likelihood ratio [LR], 0.3; 95% confidence interval [CI], 0.2-0.5). On examination, 49% of patients have an elevated blood pressure, 28% have a diastolic murmur, 31% have pulse deficits or blood pressure differentials, and 17% have focal neurological deficits. Presence of a diastolic murmur does little to change the pretest probability of dissection (positive LR, 1.4; 95% CI, 1.0-2.0), whereas pulse or blood pressure differentials and neurological deficits increase the likelihood of disease (positive LRs, 5.7 and 6.6-33.0, respectively). The plain chest radiograph results are usually abnormal (sensitivity, 90%); hence, the presence of a normal aorta and mediastinum decreases the probability of dissection (negative LR, 0.3; 95% CI, 0.2-0.4). Combinations of findings increase the likelihood of disease.
CONCLUSIONS: The presence of pulse deficits or focal neurological deficits increases the likelihood of an acute thoracic aortic dissection in the appropriate clinical setting. Conversely, a completely normal chest radiograph result or the absence of pain of sudden onset lowers the likelihood. Overall, however, the clinical examination is insufficiently sensitive to rule out aortic dissection given the high morbidity of missed diagnosis.

PMID 11980527  JAMA. 2002 May 1;287(17):2262-72.
著者: James V Quinn, Ian G Stiell, Daniel A McDermott, Karen L Sellers, Michael A Kohn, George A Wells
雑誌名: Ann Emerg Med. 2004 Feb;43(2):224-32. doi: 10.1016/S0196064403008230.
Abstract/Text STUDY OBJECTIVE: The causes of syncope are usually benign but are occasionally associated with significant morbidity and mortality. We derive a decision rule that would predict patients at risk for short-term serious outcomes and help guide admission decisions.
METHODS: This prospective cohort study was conducted at a university teaching hospital and used emergency department (ED) patients presenting with syncope or near syncope. Physicians prospectively completed a structured data form when evaluating patients with syncope. Serious outcomes (death, myocardial infarction, arrhythmia, pulmonary embolism, stroke, subarachnoid hemorrhage, significant hemorrhage, or any condition causing a return ED visit and hospitalization for a related event) were defined at the start of the study. All patients were followed up to determine whether they had experienced a serious outcome within 7 days of their ED visit. Univariate analysis was performed with chi2 and nonparametric techniques on all predictor variables. kappa Analysis was performed on variables requiring interpretation. Variables with kappa more than 0.5 and a P value less than.1 were analyzed with recursive partitioning techniques to develop a rule that would maximize the determination of serious outcomes.
RESULTS: There were 684 visits for syncope, and 79 of these visits resulted in patients' experiencing serious outcomes. Of the 50 predictor variables considered, 26 were associated with a serious outcome on univariate analysis. A rule that considers patients with an abnormal ECG, a complaint of shortness of breath, hematocrit less than 30%, systolic blood pressure less than 90 mm Hg, or a history of congestive heart failure has 96% (95% confidence interval [CI] 92% to 100%) sensitivity and 62% (95% CI 58% to 66%) specificity. If applied to this cohort, the rule has the potential to decrease the admission rate by 10%.
CONCLUSION: The San Francisco Syncope Rule derived in this cohort of patients appears to be sensitive for identifying patients at risk for short-term serious outcomes. If prospectively validated, it may offer a tool to aid physician decision making.

PMID 14747812  Ann Emerg Med. 2004 Feb;43(2):224-32. doi: 10.1016/S019・・・
著者: Matthew J Reed, David E Newby, Andrew J Coull, Robin J Prescott, Keith G Jacques, Alasdair J Gray
雑誌名: J Am Coll Cardiol. 2010 Feb 23;55(8):713-21. doi: 10.1016/j.jacc.2009.09.049.
Abstract/Text OBJECTIVES: The aim of this study was to develop and validate a clinical decision rule (CDR) to predict 1-month serious outcome and all-cause death in patients presenting with syncope to the emergency department.
BACKGROUND: Syncope is a common, potentially serious condition accounting for many hospital admissions.
METHODS: This was a single center, prospective, observational study of adults presenting to the emergency department with syncope. A CDR was devised from 550 patients in a derivation cohort and tested in a validation cohort of a further 550 patients.
RESULTS: One-month serious outcome or all-cause death occurred in 40 (7.3%) patients in the derivation cohort. Independent predictors were brain natriuretic peptide concentration > or =300 pg/ml (odds ratio [OR]: 7.3), positive fecal occult blood (OR: 13.2), hemoglobin < or =90 g/l (OR: 6.7), oxygen saturation < or =94% (OR: 3.0), and Q-wave on the presenting electrocardiogram (OR: 2.8). One-month serious outcome or all-cause death occurred in 39 (7.1%) patients in the validation cohort. The ROSE (Risk stratification Of Syncope in the Emergency department) rule had a sensitivity and specificity of 87.2% and 65.5%, respectively, and a negative predictive value of 98.5%. An elevated B-type natriuretic peptide (BNP) concentration alone was a major predictor of serious cardiovascular outcomes (8 of 22 events, 36%) and all-cause deaths (8 of 9 deaths, 89%).
CONCLUSIONS: The ROSE rule has excellent sensitivity and negative predictive value in the identification of high-risk patients with syncope. As a component, BNP seems to be a major predictor of serious cardiovascular outcomes and all-cause death. The ROSE rule and BNP measurement might be valuable risk stratification tools in patients with emergency presentations of syncope and should now be subjected to external validation.

Copyright (c) 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
PMID 20170806  J Am Coll Cardiol. 2010 Feb 23;55(8):713-21. doi: 10.10・・・
著者: Robert Sheldon, Sarah Rose, Debbie Ritchie, Stuart J Connolly, Mary-Lou Koshman, Mary Anne Lee, Michael Frenneaux, Michael Fisher, William Murphy
雑誌名: J Am Coll Cardiol. 2002 Jul 3;40(1):142-8.
Abstract/Text OBJECTIVES: We prospectively sought evidence-based criteria that distinguished between seizures and syncope.
BACKGROUND: Loss of consciousness is usually due to either seizures or syncope. There are no evidence-based historical diagnostic criteria that distinguish them.
METHODS: A total of 671 patients with loss of consciousness completed a 118-item historical questionnaire. Data sets were complete for all subjects. The data set was randomly divided into two equal groups. The contributions of symptoms to diagnoses in one group were estimated with logistic regression and point scores were developed. The accuracy of the decision rule was then assessed using split-half analysis. Analyses were performed with and without inclusion of measures of symptom burden, which were the number of losses of consciousness and the duration of the history. The scores were tested using receiver-operator characteristic analysis.
RESULTS: The causes of loss of consciousness were known satisfactorily in 539 patients and included seizures (n = 102; complex partial epilepsy [50 patients] and primary generalized epilepsy [52 patients]) and syncope (n = 437; tilt-positive vasovagal syncope [267 patients], ventricular tachycardia [90 patients] and other diagnoses such as complete heart block and supraventricular tachycardias [80 patients]). The point score based on symptoms alone correctly classified 94% of patients, diagnosing seizures with 94% sensitivity and 94% specificity. Including symptom burden did not significantly improve accuracy, indicating that the symptoms surrounding the loss of consciousness accurately discriminate between seizures and syncope.
CONCLUSIONS: A simple point score of historical features distinguishes syncope from seizures with very high sensitivity and specificity.

PMID 12103268  J Am Coll Cardiol. 2002 Jul 3;40(1):142-8.
著者: N J Lembo, L J Dell'Italia, M H Crawford, R A O'Rourke
雑誌名: N Engl J Med. 1988 Jun 16;318(24):1572-8. doi: 10.1056/NEJM198806163182404.
Abstract/Text The diagnostic accuracy of bedside maneuvers in the evaluation of patients with systolic murmurs has not been assessed objectively. Therefore, we evaluated 50 patients with documented systolic murmurs and compared all standard bedside techniques. Murmurs originating within the right-sided chambers of the heart were best differentiated from all other murmurs by augmentation of their intensity with inspiration (100 percent sensitivity, 88 percent specificity) and diminution of their intensity with expiration (100 percent sensitivity, 88 percent specificity). The murmur of hypertrophic cardiomyopathy was distinguished from all other murmurs by an increase in intensity with the Valsalva maneuver (65 percent sensitivity, 96 percent specificity) and during squatting-to-standing action (95 percent sensitivity, 84 percent specificity), and by a decrease in intensity during standing-to-squatting action (95 percent sensitivity, 85 percent specificity), passive leg elevation (85 percent sensitivity, 91 percent specificity), and handgrip (85 percent sensitivity, 75 percent specificity). The murmurs of mitral regurgitation and ventricular septal defect had parallel responses to all maneuvers, but could be differentiated from other systolic murmurs by augmentation of their intensity with handgrip (68 percent sensitivity, 92 percent specificity) and during transient arterial occlusion (78 percent sensitivity, 100 percent specificity), and by a decrease in their intensity during the inhalation of amyl nitrite (80 percent sensitivity, 90 percent specificity). No single maneuver identified the murmur of aortic stenosis, but the diagnosis could be made by exclusion. Although no single maneuver is 100 percent accurate in diagnosing the cause of a systolic murmur, its origin can be determined accurately at the bedside by observation of the response to a combination of maneuvers.

PMID 2897627  N Engl J Med. 1988 Jun 16;318(24):1572-8. doi: 10.1056/・・・

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