Stokes-Adams syndrome is a complex of symptoms caused by a sharp decrease in cardiac output and cerebral ischemia in patients suffering from severe rhythm disturbances. It manifests itself in the form of attacks of syncope, convulsions, ventricular fibrillation, asystole. The diagnosis is established by the presence of a characteristic clinical picture, changes in the electrocardiogram, the results of daily monitoring. The disease is differentiated with epilepsy, hysterical seizure. Treatment consists of resuscitation measures at the time of the development of symptoms and subsequent therapeutic restoration of normal heart function.
ICD 10
I45.9 Conduction disorder, unspecified
General information
Stokes-Adams syndrome was first described by the Italian anatomist and physician D. Morgagni in 1761. In the period from 1791 to 1878, the disease was studied by the Irish cardiologists R. Adams and V. Stokes. Taking into account the contribution of all specialists, the syndrome was named after them. Pathology is common among patients suffering from heart diseases, primarily intracardiac conduction blockades and sinus node weakness syndrome. It is more often diagnosed in people older than 45-55 years, men make up about 60% of the total number of patients. The maximum number of cases is registered in developed countries, whose residents are prone to inactivity and are exposed to cardiotoxic substances. In the “third world” states, the syndrome is relatively rare.
Causes
The development of the disease is caused by congenital organic changes in the structure of the conducting system, as well as disorders that occur under the influence of external pathogenetic factors. These include overdose with antiarrhythmic agents (novocainamide, amiodarone), occupational intoxication with organochlorine compounds (vinyl chloride, carbon tetrachloride), dystrophic and ischemic changes in the myocardium affecting large nodes of the automatism system (sinatrial, atrioventricular). In addition, the syndrome may be formed as a result of age-related degeneration of the AV center. The attack itself has the following reasons:
- Conduction blockades. The most common etiological form. Develops during the transition of an incomplete AV blockade to a full one. In this case, dissociation occurs between the atria and ventricles. The former contract under the action of impulses emanating from the CA node, the latter are excited by the AV center or ectopic foci. Partial atrioventricular blockade against the background of sinus rhythm and increased heart rate can also serve as a provoking factor.
- Rhythm disturbances. An attack is detected with an excessive rise or decrease in heart rate. Syncope is usually observed in patients with a heart rate of more than 200 or less than 30 beats per minute. In the presence of diffuse lesions of the cerebral vascular apparatus, loss of consciousness is observed already at a pulse of 40-45 beats / min. Pathology can also be potentiated by atrial fibrillation, especially when it occurs for the first time. Permanent forms of arrhythmia rarely lead to the appearance of symptoms of Stokes-Adams syndrome.
- Loss of contractile function. Occurs with ventricular fibrillation. Muscle fibers of the myocardium contract uncoordinated, separately, with a very high frequency. This makes the release of blood impossible, leads to a stop of blood circulation and the development of clinical death. It can occur with electrolyte balance disorders, have an ideopathic nature (against the background of complete health), be the result of the influence of physical factors.
Pathogenesis
It is based on a sharp reduction in cardiac output, which causes a slowdown in blood flow, insufficient supply of organs and tissues with blood, oxygen, and nutrients. Initially, nervous structures, including the brain, suffer from hypoxia. The work of the central nervous system is disrupted, loss of consciousness occurs. A little later, convulsive muscle contractions occur, indicating pronounced oxygen starvation of tissues. Prolonged seizures, especially caused by ventricular fibrillation, can lead to posthypoxic encephalopathy, multiple organ failure. While maintaining minimal blood flow (blockade, arrhythmia), the disease proceeds more easily. Seizures in most cases do not lead to delayed consequences.
Classification
Pathogenetic systematization, taking into account the causes and mechanisms of seizure formation, is used in planned treatment and the choice of preventive measures. When providing emergency care, it is more convenient to classify Stokes-Adams syndrome by the type of coronary rhythm disorder, since this allows you to quickly determine the optimal treatment tactics. There are the following types of pathology:
- Adynamic type. It is observed with the failure of the sinoatrial node, blockades of the III and II degrees, when the frequency of ventricular contractions decreases to 20-25. It includes asystole – cardiac arrest, which occurs with a sharp and complete violation of the conduction of the intracardiac pulse. A lot of time passes before the connection of alternative ectopic zones, which causes the cessation of blood circulation.
- Tachyarrhythmic type. It is determined when the heart rate increases to 200 per minute and above. It is detected with sinus tachycardia, fluttering, ventricular flicker, paroxysmal supraventricular TC, atrial fibrillation with an impulse to the ventricles by detours in Wolf-Parkinson-White syndrome.
- Mixed type. Moments of atrial or ventricular tachycardia alternate with episodes of asystole. The attack develops with a rapid decrease in heart rate from high rates to bradycardia or temporary cardiac arrest. This form is the most difficult to diagnose and prognostically unfavorable.
Symptoms
A classic seizure is characterized by rapid development and a certain sequence of changes. Within 3-5 seconds from the moment of occurrence of arrhythmia or blockade, the patient develops a pre-fainting state. Suddenly there is dizziness, headache, discoordination, disorientation, pallor. A profuse cold sweat appears on the skin. Palpatory assessment of the pulse reveals pronounced tachycardia, bradycardia or uneven rhythm.
The second stage lasts 10-20 seconds. The patient loses consciousness. Blood pressure decreases, muscle tone decreases. Acrocyanosis is visually determined, small clonic convulsions develop. With ventricular fibrillation, there is a symptom of Goering – a kind of buzzing in the xiphoid process of the sternum. After 20-40 seconds, the seizures intensify, acquire an epileptoid form, involuntary urination and defecation occur. If the rhythm is not restored after 1-5 minutes, clinical death is observed with the disappearance of pulse, respiration, corneal reflexes. The pupil is dilated, the blood pressure is not determined, the skin is pale, marble-colored.
Abortive course of the attack with reduction of symptoms within a very short time interval is possible. The cerebral cortex does not have time to undergo severe hypoxia. The main symptoms observed in this variant of pathology are dizziness, weakness, transient visual impairment, confusion. The manifestations disappear in a few seconds without medical intervention. Such types of Stokes-Adams syndrome are extremely difficult to diagnose, since similar symptoms are detected in many other conditions, including cerebrovascular disease.
Complications
The syndrome leads to a number of complications, the main of which is clinical death. Prolonged stoppage of blood flow is a factor in the death of part of the cells of the cerebral cortex. After successful resuscitation, this causes encephalopathy, somatic disorders, and a decrease in the patient’s mental abilities. The number of complications can include changes in the psychoemotional background of a patient who is constantly experiencing fear of the onset of a new crisis, which negatively affects the quality of life, productivity of work and rest. During the loss of consciousness and falling to the ground, the patient may receive injuries, which are also attributed to pathological conditions associated with Stokes-Adams syndrome.
Diagnostics
The primary diagnosis is carried out by the ambulance employees who arrived on the call. The final diagnosis is made by a cardiologist based on the results of electrocardiography and Holter monitoring. Differential diagnosis is carried out with an epileptic seizure, hysteria. A distinctive feature of true epilepsy is the change of tonic convulsions to clonic ones, facial hyperemia, preceding aura. With the hysterical origin of the pathology, loss of consciousness does not occur, there is a sinus heart rhythm. Signs of Stokes-Adams syndrome are considered to be the presence of arrhythmias of one kind or another, the rapid development of the clinical picture. In the process of diagnostic search, the following methods are used:
- Physical examination. Typical symptoms are noted, the condition develops quickly (within a few tens of seconds). In the anamnesis there are diseases of a cardiological profile, immediately before the attack, an episode of psychoemotional excitement, experiences is possible. Blood pressure is sharply reduced or not measured, the heart rate is uneven. The type of violation can be determined only by the results of an ECG.
- Instrumental examination. The main method of hardware diagnostics is electrocardiography. At the moment of symptoms, negative expanded “T” teeth in leads V4-V2 are recorded on the film. The presence of deformed ventricular complexes is possible. During blockades, dissociation of “P” with “QRS”, oblique depression of the “ST” segment is observed. Fibrillation is manifested by the absence of normal activity on the ECG, the appearance of a small or large wavy line. With the help of daily monitoring, it is possible to detect a transient blockade, against which an attack occurs.
- Laboratory examination. It is carried out in order to determine the causes of the disease and its consequences. After an episode of clinical death, a change in the pH level to the acidic side, electrolyte deficiency, and the presence of myoglobin in the blood are detected. In coronary diseases, the growth of cardiospecific markers is possible: troponin, CFK MV.
Emergency care
Help with Stokes-Adams syndrome includes direct relief of the attack and prevention of relapses. With a developing seizure, rescue measures are carried out by a medical worker present, regardless of his profile and specialization. Combined resuscitation measures are carried out. Treatment includes:
- Termination of the seizure. The same algorithm is used as in cardiac arrest. It is recommended to perform a precardial stroke, indirect massage, in the absence of breathing – ventilation by mouth-to-mouth or using appropriate equipment. With VF, electrical defibrillation is performed. Adrenaline, atropine, calcium chloride, and inotropic agents are injected intravenously. With tachyarrhythmia, antiarrhythmic drugs are indicated: amiodarone, novocainamide.
- Seizure prevention. If the attacks are caused by paroxysms of TA, the patient needs medications to stabilize the myocardium and equalize the heart rhythm. In case of blockades, drug therapy is ineffective, the implantation of an asynchronous or demand pacemaker is necessary. With reciprocal tachycardia, operative destruction of one of the conducting pathways of the AV node is possible.
Prognosis and prevention
The prognosis is favorable with rapid relief of the attack and with its abortive variant. Normalization of the heart rate and blood supply to the brain within 1 minute from the moment of formation of the clinical picture is not accompanied by delayed consequences. A long period of asystole or ventricular fibrillation reduces the likelihood of a successful recovery of the coronary rhythm and increases the risk of ischemic brain damage. Specific preventive measures have not been developed. General recommendations for the prevention of cardiac diseases include quitting smoking and alcohol, exclusion of physical inactivity, sports, compliance with the principles of healthy eating. When the first signs of heart disorders appear, you should consult a doctor for examination and treatment.