Tóm tắt hướng dẫn đánh giá và điều chỉnh bệnh nhân ngất của Acc/Aha/Hrs 2017 – P1 | Tim mạch học

Tháng 3 năm 2017, Trường Môn Tim mạch học Hoa Kỳ, Hội Tim Hoa Kỳ và Hội Nhịp Tim học Hoa Kỳ (ACC/AHA/HRS) đã đưa ra Hướng dẫn đánh giá và điều chỉnh các bệnh nhân ngất.

TS Phạm Hữu Văn

Hướng dẫn này có nhiều cập nhật mang tính cơ bản, trong đó thay đổi một số quan niệm. Chúng tôi xin được tóm tắt khuyến cáo này. Xin trân trọng giới thiệu với các quý đồng nghiệp.

Class khuyến cáo và mức độ (Level) bằng chứng

Class khuyến cáo (COR) chỉ ra sức mạnh của khuyến cáo, bao gồm độ lớn ước tính và mức độ chắc chắn của lợi ích tương ứng với rủi ro. Mức độ bằng chứng (LOE) đánh giá chất lượng của các bằng chứng khoa học ủng hộ can thiệp dựa trên loại, số lượng, sự thống nhất của dữ liệu từ các thử nghiệm lâm sàng và các nguồn khác (Bảng 1) (4-6).

Bảng 1. Áp dụng Class khuyến cáo và Mức độ bằng chứng cho các Chiến lược Lâm sàng, Can thiệp, Điều trị, hoặc Tests Chẩn đoán trong Chăm sóc Bệnh nhân * (Updated August 2015)

Class (độ mạnh) khuyến cáo (COR)	Mức độ (chất lượng) bằng chứng (LOE)
Class I (mạnh) Lợi ích >>> Nguy cơ	Mức độ A
Cụm từ được gợi ý cho soạn khuyến cáo: ■ Được khuyến cáo ■ Được chỉ định / hữu dung / hiệu quả /lợi ích. ■ Nên được thực hiện /áp dụng/các vấn đề khác ■ Cụm từ so sánh hiệu quả†: ○ Điều trị / chiến lược A được khuyến cáo / được điều trị ưu tiên hơn điều trị B. ○ Điều trị A nên được lựa chọn hơn B	■ Bằng chứng chất lượng cao ‡từ ≥ 1 RCT. ■ Phân tích gộp của RCTs có chất lượng cao. ■ 1 hoặc hơn RCTs được xác nhận bằng các nghiên cứu đăng ký có chất lượng cao.
	Mức độ B-R (R: ngẫu nhiên)
	■ Bằng chứng chất lượng trung bình ‡từ ≥ 1 RCTs. ■ Các phân tích gộp của RCTs có chất lượng trung bình.
Class IIa (trung bình) Lợi ích >> Nguy cơ	Mức độ B-NR (NR: không ngẫu nhiên)
Cụm từ được gợi ý cho soạn khuyến cao: ■ Phù hợp ■ Có thể hữu dụng /hiệu quả/lợi ích ■ Cụm từ so sánh hiệu quả†: ○ Điều trị / chiến lược A có lẽ được khuyến cáo / được điều trị ưu tiên hơn điều trị B. ○ Điều phù hợp để lựa chọn điều trị A hơn điều trị B	■ Bằng chứng chất lượng trung bình ‡từ ≥ 1 nghiên cứu không ngẫu nhiên được thực thi, thiết kế tốt, các nghiên cứu quan sát, hoặc các nghiên cứu đăng ký. ■ Các phân tích gộp của các nghiên cứu như vậy.

	Mức độ C-LD (Tư liệu hạn chế)
	■ Các nghiên cứu quan sát hoặc đăng ký ngẫu nhiên hoặc không ngẫu nhiên với hạn chế về thiết kế và thực thi. ■ Phân tích gộp các nghiên cứu như vậy. ■ Nghiên cứu sinh lý học và máy móc ở các đối tượng người.
Class IIb (yếu) Lợi ích ≥ Nguy cơ	Mức C-EO (Lựa chọn của chuyên gia)
Các cụm từ được gợi ý cho soạn thảo khuyến cáo: ■ Có lẽ /Có thể là phù hợp ■ Có lẽ /Có thể được xem xét ■ Hữu dụng /Hiệu quả chưa được biết/không rõ/không chắc chắn hoặc chưa được tính toán rõ.	Sự đồng thuận của các lựa chọn các chuyên gia trên cơ sở kinh nghiệm lâm sàng.
Class III (không lợi ích) Lợi ích = Nguy cơ	Class khuyến cáo và mức độ bằng chứng được xác định độc lập (bất ký class nào có thể đi đôi với bất ký mức độ bằng chứng nào) Các khuyến cáo mức độ C không ngụ ý khuyến cáo là yếu. Nhiều câu hỏi lâm sàng quan trọng được nhấn mạnh trong hướng dẫn không tự giúp sức cho các nghiên cứu lâm sàng. Mặc dù RCTs không có khả năng, có thể sự đồng thuận lâm sàng rất rõ ràng đó là các tests đặc biệt hoặc điều trị là hữu dụng hoặc hiệu quả. * Hẫu quả và kết quả của can thiệp nên được xác định (Hậu quả lâm sàng được cải thiện hoặc độ chính xác của chẩn đoán được tăng lên hoặc các thông tin tiên lượng được tăng lên. † Cho các khuyến cáo hiệu quả được so sánh (class I và IIa, mức độ chứng cứ A và chỉ B), các nghiên cứu ủng hộ động từ so sánh liên quan so sánh các điều trị hoặc chiến lược trực tiếp đang được đánh giá. ‡Các phương pháp chất lượng đánh giá đang phát triển, gồm chuẩn hóa, sử dụng rộng rãi và ưa chuộng các bằng chứng có giá trị phân loại công cụ; cả cho xem xét hệ thống, kết hợp của Ủy ban Xem xét Bằng chứng. OE: sự lựa chọn của chuyên gia. LD: tư liệu hạn chế. NR: không ngẫu nhiên. R: ngẫu nhiên.
Các cụm từ được gợi ý cho soạn thảo khuyến cáo: ■ Không được khuyến cáo ■ Không được chỉ định /hữu dụng/hiệu quả/lợi ích. ■ Không nên thực hiện /áp dụng/các cái khác
Class III: hại (mạnh) Nguy cơ > Lợi ích
Các cụm từ được gợi ý cho soạn thảo khuyến cáo: ■ Hại tiềm ẩn ■ Gây hại ■ Kết hợp với bệnh suât / tử suất vượt trội ■ Không nên thực hiện /áp dụng/các cái khác

1. Mở đầu

1.1. Nhắc lại Phương pháp luận và Bằng chứng

Bất cứ khi nào có thể, các bằng chứng được dựa trên cơ sở đều được liệt kê khuyến cáo trong hướng dẫn này. Nhắc lại bằng chứng hiểu biết thông thường bao gồm các tài liệu có nguồn gốc từ các nghiên cứu liên quan đến con người, được xuất bản bằng tiếng Anh và được lập chỉ mục trong MEDLINE (thông qua PubMed), EMBASE, Thư viện Cochrane, Cơ quan Nghiên cứu và Chất lượng Y tế và các cơ sở dữ liệu được lựa chọn khác có liên quan đến được tiến hành từ tháng 7 đến tháng 10 năm 2015. Các từ tìm kiếm chủ chốt gồm có: vận động viên, bệnh lý thần kinh tự trị, nhịp tim chậm, tăng cảm xoang cảnh, hội chứng xoang cảnh, trẻ em, tử vong, mất nước, chẩn đoán, lái xe, điện tâm đồ, nghiên cứu điện sinh lý, dịch tễ học, té ngã, máy ghi vòng lặp có thể cấy, tử xuất, quần thể lớn tuổi, hạ huyết áp tư thế đứng, nhi khoa, giả ngất tâm lý, ngất tái phát, phân tầng nguy cơ, nhịp nhanh trên thất, đơn vị ngất, ngất, test bàn nghiêng, ngất phế vị. cũng như rối loạn nhịp thất. Các nghiên cứu bổ sung có liên quan được công bố vào tháng 10 năm 2016, trong quá trình biên soạn hướng dẫn, cũng được ban soạn thảo xem xét và bổ sung vào bảng chứng cứ khi thích hợp. Các bảng bằng chứng đã hoàn tất, bao gồm trong phần Bổ sung Dữ liệu Trực tuyến (http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIR.0000000000000499/-/DC2). tóm tắt bằng chứng được ban soạn thảo để theo thể thức các khuyến cáo được sử dụng. Sau cùng, ban soạn thảo đã nhắc lại các tư liệu liên quan đến ngất được ACC và AHA cũng như các tổ chức và các hội mới xuất bản. Tài liệu tham khảo được lựa chọn và công bố trong tài liệu này là đại diện chứ không phải là tất cả.

ERC độc lập đã được ủy nhiệm để thực hiện xem xét có hệ thống các câu hỏi lâm sàng, kết quả đã được ban soạn thảo xem xét để đưa vào hướng dẫn này. Báo cáo đánh giá có hệ thống “Tạo nhịp như một phương pháp điều trị chứng Ngất qua Trung gian Phản xạ (Cường phế vị, Tình huống, hoặc Tăng cảm Xoang Cảnh)” đã được xuất bản cùng với hướng dẫn này (9).

1.2. Tổ chức Ban Soạn thảo

Ủy ban soạn thảo gồm các nhà lâm sàng có chuyên môn chăm sóc bệnh nhân ngất, gồm bác sĩ tim mạch, bác sỹ điện sinh lý, bác sĩ thần kinh, bác sĩ cấp cứu và bác sĩ tim mạch nhi. Ủy ban soạn thảo gồm các đại diện từ ACC, AHA, Hội Nhịp Tim (HRS), Học viện Thần kinh Hoa Kỳ, Trường Đại học Y Cấp cứu Hoa Kỳ và Hội Viện Y học Cấp cứu.

1.3. Xem xét Tư liệu và Phê duyệt

Tài liệu này được hai nhà phê bình chính thức do ACC, AHA và HRS đề cử xem xét; 1 người đánh giá từ Học viện thần kinh học Hoa Kỳ, Trường Đại học Y khoa Cấp cứu Hoa Kỳ và Hội Y học Khẩn cấp Y khoa và Hội Điện sinh học Nhi khoa và Bẩm sinh; Một đại diện những người được huấn luyện đào tạo chuyên môn cao về ngất / bệnh nhân; Và 25 nhà phê bình ưa thích riêng biệt. Thông tin RWI của người đánh giá đã được phân phát cho ủy ban soạn thảo và được xuất bản trong tài liệu này (Phụ lục 2).

Tài liệu này đã được cơ quan quản lý của ACC, AHA và HRS phê duyệt để công bố và đã được Hội Điện sinh lý học Nhi khoa và Bẩm sinh xác nhận.

1.4. Phạm vi Hướng dẫn

Mục đích của hướng dẫn này của ACC / AHA / HRS là cung cấp hướng dẫn đương đại, dễ tiếp cận và ngắn gọn về quản lý bệnh nhân người lớn và nhi khoa bị nghi ngờ ngất. Hướng dẫn này là tài liệu thiết thực cho các nhà tim mạch, các chuyên gia về loạn nhịp tim, bác sĩ thần kinh, bác sĩ cấp cứu, chuyên viên nội khoa, chuyên gia lão khoa, chuyên gia y học thể thao và các chuyên gia chăm sóc sức khoẻ khác có liên quan đến việc chăm sóc quần thể rất lớn và không đồng nhất này. Nó không phải là một tổng quan về sinh lý học, sinh lý bệnh học, hoặc cơ chế các trạng thái cơ bản liên quan đến ngất. Bản chất của ngất như một triệu chứng đòi hỏi ủy ban soạn thảo phải cân nhắc nhiều điều kiện nó có thể là một triệu chứng, và càng nhiều càng tốt, chúng ta đã đề cập đến sự dính líu của ngất chỉ như biểu hiện triệu chứng. Do sự liên quan hợp lý của ngất và đột tử tim (SCD) ở một số quần thể được lựa chọn, tài liệu này thảo luận về phân tầng nguy cơ và dự phòng SCD khi thích hợp. Việc sử dụng thuật ngữ quần thể được lựa chọn và các bệnh nhân được lựa chọn trong tài liệu này nhằm hướng các nhà cung cấp dịch vụ chăm sóc sức khoẻ thực hiện việc đánh giá lâm sàng, điều này thường được yêu cầu trong quá trình đánh giá và quản lý bệnh nhân bị ngất. Khi một khuyến cáo đưa ra để giới thiệu bệnh nhân tới chuyên gia có chuyên môn để đánh giá thêm, chẳng hạn như trong trường hợp bệnh thần kinh tự trị, bệnh tim bẩm sinh người lớn (ACHD), người cao tuổi hoặc vận động viên, ủy ban soạn thảo đã đồng ý đưa ra các khuyến cáo Class IIa do thiếu dữ liệu kết quả. Định nghĩa về các quần thể lớn tuổi đã và đang phát triển. Tuổi> 75 năm được sử dụng để xác định các quần thể lớn tuổi những người lớn tuổi hoặc người cao tuổi trong tài liệu này, trừ khi có quy định khác. Nếu một nghiên cứu đã định nghĩa người lớn tuổi bằng cách cắt giảm tuổi khác nhau, độ tuổi thích hợp được ghi nhận trong những trường hợp cụ thể. Cuối cùng, hướng dẫn này đề cập đến việc quản lý ngất với bệnh nhân như một trọng tâm, thay vì các khía cạnh lớn hơn của các dịch vụ y tế, chẳng hạn như các đơn vị quản lý ngất. Các mục tiêu của hướng dẫn hiện tại là:

• Xác định ngất như một triệu chứng, với các nguyên nhân khác nhau, trong các quần thể và hoàn cảnh khác nhau.

• Cung cấp hướng dẫn và các khuyến cáo về đánh giá và quản lý bệnh nhân nghi ngờ ngất trong bối cảnh các tỉnh trạng lâm sàng khác nhau, nguyên nhân cụ thể hoặc các tình huống được chọn.

• Xác định các lĩnh vực trọng yếu trong đó sự hiểu biết có đang thiếu, để thúc đẩy các cơ hội nghiên cứu hợp tác và các nỗ lực trong tương lai.

Trong việc xây dựng hướng dẫn này, ủy ban soạn thảo đã xem xét các bằng chứng để hỗ trợ các khuyến cáo trong các hướng dẫn ACC / AHA có liên quan ghi trong Bảng 2 và khẳng định tính hợp lệ liên tục của các khuyến cáo liên quan trong bối cảnh ngất, do đó bỏ qua sự cần thiết phải lặp lại những gợi ý hướng dẫn hiện tại trong Hướng dẫn hiện hành khi áp dụng hoặc khi thích hợp. Bảng 2 cũng bao gồm một danh sách các tuyên bố khác có thể được người đọc quan tâm.

Bảng 2. Các hướng dẫn của ACC/AHA có liên quan

Tự đề	Các tổ chức	Năm xuất bản (TL tham khảo)
Chính sách có liên quan đến điều chỉnh ngất của các hướng dẫn của ACC/AHA
Nhịp nhanh trên thất	ACC/AHA/HRS	2015 (10)
Bệnh van tim	AHA/ACC	2014 (11)
Điều trị các bất thường nhịp tim trên cơ sở dụng cụ	ACCF/AHA/HRS	2012 (12)
Rối loạn nhịp thất và đột tử tim	ACC/AHA/ESC	2006 (13)*
Các hướng dẫn quan tâm khác của ACC/AHA
Tăng huyết áp*	ACC/AHA	—
Bệnh tim thiếu máu cục bộ ổn định	ACC/AHA/ACP/ AATS/PCNA/SCAI/STS	2012 and 2014 (14,15)
Rung nhĩ	AHA/ACC/HRS	2014 (16)
Hội chứng mạch vành cấp ST không chênh lên.	AHA/ACC	2014 (17)
Đánh giá nguy cơ tim mạch	ACC/AHA	2013 (18)
Suy tim	ACC/AHA	2013 (19)*
Bệnh cơ tim phì đại	ACC/AHA	2011 (20)
Đánh giá nguy cơ tim mạch ở người lớn không triệu chứng.	ACC/AHA	2010 (21)
Bệnh tim bẩm sinh người lớn	ACC/AHA	2008 (22)*
Các tài liệu liên quan khác
Báo cáo khoa học về tái cực sớm trên điện tâm đồ.	AHA	2016 (23)
Sự đồng thuận của chuyên gia về chẩn đoán và điều trị hội chứng nhịp nhanh tư thế, nhịp xoang nhanh không thích hợp và ngất phế vị.	HRS	2015 (24)
Hướng dẫn điều chỉnh các bệnh nhân loạn nhịp thất và dự phòng đột tử tim.	ESC	2015 and 2013 (25,26)
Tuyên bố đồng thuận về ghi nhận và điều chỉnh rối loạn nhịp ở bệnh tim bẩm sinh người lớn.	PACES/HRS	2014 (27)
Tuyên bố đồng thuận của chuyên gia về việc sử dụng điều trị cấy máy khử rung tim ở những bệnh nhân không có hoặc không được đại diện rõ trong các thử nghiệm lâm sàng.	HRS/ACC/AHA	2014 (28)
Tuyên bố đồng thuận của chuyên gia về rối loạn nhịp thất.	EHRA/HRS/APHRS	2014 (29)
Tuyên bố đồng thuận của chuyên gia về chẩn đoán điều chỉnh các bệnh nhân hội chứng loạn nhịp di truyền tiên phát.	HRS/EHRA/APHRS	2013 (25)
Các hướng dẫn cho chẩn đoán và điều chỉnh ngất.	ESC	2009 (30)

*Các bản sửa đổi cho các tài liệu hiện tại đang được chuẩn bị, với công bố dự kiến vào năm 2017. AATS: Hội Ngoại khoa Lồng ngực Hoa Kỳ; ACC: Trường môn Tim mạch học Hoa Kỳ; ACCF: Ban sáng lập Trường môn Tim mạch học Hoa Kỳ; ACP: Hội Các Thày thuốc Hoa Kỳ; AHA: Hội Tim Hoa Kỳ; APHRS: Hội Nhịp Tim Châu Á Thái Bình Dương; EHRA: Hội Nhịp Tim Châu Âu; ESC: Hội Tim mạch học Châu Âu; HRS: Hội Nhịp Tim; PACES: Hội Điện sinh lý Bẩm sinh và Nhi khoa; PCNA: Hội Điều dưỡng Tim mạch dự phòng; SCAI: Hội Chụp mạch và Can thiệp Tim mạch; và STS: Hội Ngoại khoa Lồng ngực

2. Các nguyên tắc chung

2.1. Các khái niệm: Các thuật ngữ và Phân loại

Cho mục đích của hướng dẫn này, các khái niệm ngất và các thuật ngữ liên quan được cung cấp ở Bảng 3.

Bảng 3. Các Khái niệm và Các thuật ngữ liên quan*

Thuật ngữ	Khái niệm / Các bình lận và Tài liệu tham khảo
Ngất	Triệu chứng biểu hiện với mất ý thức đột ngột, tạm thời, hoàn toàn, kết hợp với mất khả năng để duy trì trương lực tư thế, với phục hồi nhanh chóng và tự phát. Cơ chế được giả định do giảm tưới máu não (24,30). Không có các đặc điểm lâm sàng của các nguyên nhân mất ý thức không phải do ngất khác, như co giật, chấn thương đầu trước đó, hoặc mất ý thức không đồng bộ khác của việc mất ý thức, chẳng hạn như động kinh, chấn thương đầu trước, hoặc mất ý thức rõ ràng (nghĩa là ngất giả) (24,30).
Mất ý thức	Trạng thái nhận thức trong đó một người mất nhận thức về bản thân và trạng thái của mình, với mất khả năng đáp ứng lại các kích thích.
Mất ý thức tạm thời	Mất ý thức tự giới hạn (30) có thể được chia ra tính trạng ngất và không ngất. Các trạng thái không ngất gồm nhưng có giật không tự giới hạn, hạ đường máu, các trạng thái rối loạn chuyển hóa, ma túy hoặc nhiễm độc alcohol, chấn động não do chấn thương đầu. Cơ chế nền tảng của ngất được giả định do giảm tưới máu não, ngược lại các trạng thái không phải ngất do các cơ chế khác nhau.
Tiền ngất (gần ngất)	Các triệu chứng trước khi ngất. Những triệu chứng này có thể bao gồm chóng mặt cực độ; lóa mắt, chẳng hạn như “nhìn mờ” hoặc “tối sầm”; mức độ thày đổi ý thức khác nhau không có mất ý thức. Tiền ngất có thể tiến triển đến ngất, hoặc có thể không đi đến ngất.
Ngất không giải thích được (ngất căn nguyên không xác định)	Ngất do không xác định được nguyên nhân sau khi đánh giá khởi đầu do người chăm sóc sức khỏe có kinh nghiệm được cho là phù hợp. Đánh giá ban đầu gồm nhưng không được giới hạn qua bệnh sử, khám thực thể và ECG.
Không dung náp tư thế	Một hội chứng gồm một nhóm các triệu chứng gồm choáng vàng, hồi hộp run rẩy, duối sức thông thường, nhìn mờ, kém chịu dựng gắng sức thường xuyên, tái phát hoặc dai dẳng. Các triệu chứng này có thể xuất hiện có hoặc không có nhịp nhanh tư thế, OH, hoặc ngất (24). Các cá nhân kém chịu đựng tư thế có ≥ 1 các triệu chứng này liên quan đến giảm khả năng duy trì tư thế đứng thẳng.
Nhịp nhanh tư thế	Tăng tần số tim kéo dài ≥30 bpm trong phạm vi 10 min của chuyển từ nằm sang tư thế đứng yên (không gắng sức) (hoặc ≥40 bpm ở các cá nhân 12–19 tuổi) (24,30,31).
Hạ huyết áp tư thể (OH)	Giảm huyết áp tâm thu ≥20 mm Hg hoặc huyết áp tâm trương ≥10 mm Hg với giả định sang tư thế đứng thẳng (31).
• OH khởi đầu (ngay lập tức)	Giảm huyết áp tạm thời trong phạm vi 15 s sau khi đứng, với gần ngất hoặc ngất (31,32).
• OH kinh điển	Giảm huyết áp tâm thu kéo dài ≥20 mm Hg hoặc huyết áp tâm trương ≥10 mm Hg trong phạm vi 3 phút giả định sang tư thế đứng thẳng (31).
• OH trễ	Giảm huyết áp tâm thu kéo dài ≥20 mm Hg (hoặc 30 mm Hg ở các bệnh nhân với tăng huyết áp khi nẳm ngửa) hoặc huyết áp tâm trương ≥10 mm Hg phải mất 3 phút để đứng thẳng để phát triển. Sự sụt giảm BP thường dần dần cho đến khi đạt đến ngưỡng (31).
• OH do thần kinh	Phân type OH do rối loạn chức năng hệ thống thần kinh tự động và không liên quan đến khởi kích của môi trường (như, mất nước hoặc thuốc) (33,34). OH do thần kinh là do tổn thương liên quan đến thần kinh tự động trung ương hoặc ngoại biên.
Ngất do tim (tim mạch)	Ngất gây ra do nhịp chậm, nhịp nhanh, hoặc do hạ huyết áp do chỉ số tim thấp, tắc nghẽn dòng máu, giãn mạch, hoặc bóc tách mạch cấp tính (35,36).
Ngất không do tim	Ngất do các nguyên nhân không phải tim gồm ngất phản xạ, OH, cạn thể tích, mất nước và mất máu (35).
Ngất phản xạ (qua trung gian phản xạ)	Ngất do phản xạ gây ra giãn mạch, nhịp chậm hoặc cả hai (24,30,31).
• Ngất phế vị (VVS)	Hình thái chung nhất của ngất phản xạ qua trung gian phản xạ phế vị (vasovagal reflex syncope: VVS). VVS 1) có thể xuất hiện với tư thế thẳng đứng (đang đứng hoặc đã ngồi hoặc với bộc lộ stress xúc cảm, đau, hoặc các trạng thái do thuốc); 2) điển hình được đặc trưng bằng toát mồ hôi, hâm hấp, buồn nôn, và ngứa; 3) được kết hợp với hạ huyết áp do giãn mạch và / hoặc nhịp chậm không phù hợp: và 4) thường tiếp theo bằng mệt mỏi. Các đặc tính điển hình có thể không có ở các bệnh nhân lớn tuổi (24). VVS thường có các khởi kích có thể nhận biết được đi trước và hoặc bằng các triệu chứng đặc trưng sớm. Chẩn đoán được thực hiện trước tiên trên cơ sở bệnh sử đầy đủ, khám xét thực thể và quan sát của nhân chứng, nếu có thể.
• Hội chứng cường xoang cảnh	Ngất phản xạ được kết hợp với cường xoang cảnh (30). Cường xoang cảnh biểu hiện khi khoảng ngưng ≥3 s và /hoặc giảm huyết áp tâm thu ≥50 mm Hg xuất hiện khi kích thích xoang cảnh. Nó xuất hiện thường xuyên hơn ở người già. Cường xoang cảnh có thể kết hợp với các triệu chứng khác nhau. Hội chứng xoang cảnh được xác định khi ngất xảy ra có biểu hiện cường xoang cảnh.
• Ngất tình huống	Ngất phản xạ kết hợp với hoạt động cụ thể, như ho, cười, nuốt, đi tiểu (micturition), hoặc đại tiện. Những sự kiện ngất này có liên quan chặt chẽ với các chức năng thể chất cụ thể.
Hội chứng nhịp nhanh tư thế (tư thế đúng) (POTS)	Hội chứng lâm sàng thường được đặc trưng bằng tất cả những điều sau đây: 1) các triệu chứng thường gặp xảy ra khi đứng (ví dụ như lâng lâng, đánh trống ngực, run rẩy, suy yếu nói chung, nhìn mờ, không chịu được gắng sức và mệt mỏi); và 2) gia tăng nhịp tim ≥ 30 bpm trong thời gian thay đổi tư thế từ nằm sang đứng (hoặc ≥ 40 bpm ở những người từ 12-19 tuổi); và 3) vắng mặt của OH (giảm huyết áp tâm thu > 20 mm Hg). Các triệu chứng liên quan đến POTS bao gồm những triệu chứng xảy ra khi đứng (ví dụ, chóng mặt, đánh trống ngực); Những người không liên quan đến các tư thế cụ thể (ví dụ như đầy bụng, buồn nôn, tiêu chảy, đau bụng); và những bệnh có hệ thống (ví dụ, mệt mỏi, rối loạn giấc ngủ, nhức đầu migraine) (37). Tần số tim khi đứng thường là> 120 bpm (31,38-42).
Giả ngất tâm lý	Một hội chứng rõ ràng nhưng không thực sự mất ý thức có thể xảy ra trong trường hợp không có các nguyên nhân về tim, phản xạ, thần kinh, hay trao đổi chất (30).

* Các định nghĩa này được rút ra từ các định nghĩa được xuất bản trước đây từ các cuộc điều tra khoa học, các hướng dẫn, các tuyên bố đồng thuận của chuyên gia và từ điển Webster sau khi có được sự đồng thuận từ WC. BP chỉ huyết áp; ECG: điện tâm đồ; OH: hạ huyết áp tư thế đứng; POTS: hội chứng nhịp nhanh thay đổi tư thế; VVS: ngất phế vị. bpm: nhịp đập trong 1 phút. min: phút.

(Còn nữa…)

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