Introduction: T he complications of syncope affect patients and peers alike. Correct identification and, consequently, adequate treatment of syncope are more complex in the elderly. Coexisting conditions can cause syncope either independently or by interacting.
Case presentation: We present the case of a hypertensive 73-year-old male, former soccer instructor, with known ischemic history and frequent syncopal occurrences. They occur upon standing and are rarely preceded by prodromal symptoms (dizziness, fading vision). The patient also mentions a post micturition syncope. He was, recently diagnosed with ischemic cerebral vascular accident in the right frontal territo-ry, with complete neurological recovery. At admission he has moderate effort tolerance but has orthostatic hypotension. The electrocardiogram shows first degree atrioventricular block and complete left bundle bran-ch block. The echocardiography shows severe cavities dilation, severely reduced ejection fraction and severe functional mitral regurgitation
The cardiac electrophysiology study proves an infra-His atrioventricular block, supporting that the patient has an indication of permanent pacemaker implantati-on. In addition, the coronary catheterization revealed no significant coronary stenosis. Therefore, beside the ischemic history, a type of cardiomyopathy may also be a cause of the reduced ejection fraction. Considering the severely reduced ejection fraction, the complete left bundle branch block and a QRS duration of 200 msec., cardiac resynchronization therapy with implantable cardioverter-defibrillator was provided. The following day, another syncopal episode occurred, and the ECG showed typical atrial flutter. Pharmacologic cardio-version was performed. The 6-month reexamination showed that, despite strict therapeutic adherence, the patient had multiple additional syncopal occurrences, some of them resulting in physical injury.
Conclusions: Recurring syncope in this patient supports the multifactorial etiology of his symptoms. The adequate treatment of the cardiac cause of the syncope (clinical, imagistic and electrophysiological diagnosis) is limited, nonetheless, by reflex causes, orthostatic hypotension and the preexistent neurological disease. Properly managing this type of patients implies lowering accident risk and ease psycho-social implications, for which a non-pharmaceutical approach, patient education and counseling are essential.