SYNCOPE a symptom, not a diagnosis…

1. SYNCOPEa symptom, not a diagnosis… Dr Jaycen Cruickshank Ballarat Emergency Education Grampians Emergency Medicine Training Hub

2. Syncope Learning objectives Learning objectives To name the common and important medical conditions that cause syncope and their characteristic features on history and exam To rapidly diagnose life threatening causes of syncope To interpret ECGs to detect arrhythmias and risk of the same Pre reading Hughes T & Cruickshank J. Adult Emergency Medicine at a Glance. Chichester, West Sussex, UK : John Wiley & Sons, 2011. Chapter 21 Slow heart rate. Chapter 32 Fast heart rate. Chapter 34 Chest pain: cardiovascular. Chapter 35 Chest pain: non cardiovasular Other learning resources Cruickshank J. Initial management of cardiac arrhythmias. Vol 37, (7) 516-520 2008 Australian Family Physician. http://www.racgp.org.au/afp/200807/200807cruickshank.pdf Ballarat Grampians Emergency Medicine Training Hub

3. Learning Objectives Definition – what it is / is not • When you assess the patient in front of you, are you using your differential diagnosis list for syncope… or for something else? An approach to diagnosis includes • pattern recognition for situational syncope, risk stratification when no clear diagnosis… & • Recognition of ECGs (rare & deadly) • Admission criteria Ballarat Grampians Emergency Medicine Training Hub

4. Preparation slidesThese may be pre reading +/- presented by teacher This presentation is prepared for tutors to deliver, for self directed learning. The notes below should assist Ballarat Grampians Emergency Medicine Training Hub

5. Definition of syncope “a transient loss of consciousness due to transient global cerebral hypoperfusion characterized by rapid onset, short duration, and spontaneous complete recovery.” (European Soc Cardiology 2009) Means a LOC with full recovery Involves a loss of postural tone Spontaneous recovery (not CPR/DCR) Reasonable to think of pre-syncope as the same problem (overlap with dizziness etc) Ballarat Grampians Emergency Medicine Training Hub

6. What syncope does not mean – 3 rulesThis relates to which feature could be considered the primary presenting symptom Syncope + headache = headache • Think serious causes of headache • e.g subarachnoid haemorrhage Syncope + chest pain = chest pain • Think cardiac ischaemia or arrhythmia Syncope + dyspnea = dyspnea • Think pulmonary embolus Similar concept for other symptoms e.g gastronintestinal symptoms Ie think of syncope as perhaps a severe manifestation of other illnesses, you have a sick patient and getting some senior clinical input is advisable early on. Ballarat Grampians Emergency Medicine Training Hub

7. Epidemiology 58% Vasovagal – neurally mediated 23% arrhythmia 18% unexplained 1% neurology or psychiatric Ballarat Grampians Emergency Medicine Training Hub

8. History - aims Determine that syncope is main problem Attempt to identify a cause Start risk stratification Ballarat Grampians Emergency Medicine Training Hub

9. Is syncope the problem? Headache/chest pain/dysnpea will be dealt with in other sessions Fit versus faint – • Tutor to ask for input from the audience in differentiating features (in the pre reading) Define typical vasovagal (prior symtoms, stimulus, recurrence) Demonstration http://www.youtube.com/watch?v=nfWUhCL0A-I http://www.youtube.com/watch?v=Nds2U4CzvC4 Ballarat Grampians Emergency Medicine Training Hub

10. All features check with witnesses or pre hospitalAsk patient what happened preceding the episode Postural issues – hypotension, prolonged standing Fear, pain Situational syncope Cough, micutirition, defecation Neck movement association -carotid sinus syndrome On exertion = high risk • Aortic stenosis • HOCM • Ventricular arrhythmia, • QT prolongation Ballarat Grampians Emergency Medicine Training Hub

11. Pre existing conditions / meds Cardiac failure is the most important independent risk factor for mortality associated with syncope. Ask for pre-existing conditions Ask about previous episodes and tests already performed Family history of sudden death • (think QT, HOCM) Medications (prolonged QT, combinations) Ballarat Grampians Emergency Medicine Training Hub

12. Examination – not that useful Look for postural drop & tachycardia (>20) Cardiac – Listen for systolic murmurs • Aortic stenosis • HOCM and cardiac failure ALSO THINK OF COMPLICATIONS • Eg. Trauma from the fall Low yield Vascular – AAA, carotid bruit (?useful) Neuro is probably useless Ballarat Grampians Emergency Medicine Training Hub

13. InvestigationsNo precise rules on who needs them BSL prob no use (given recovery) • Note Many Emergency Departments have a DEFG rule (Don’t ever forget glucose) ECG’s are simple , non-invasive and quick and between episodes can detect risk of arrhythmias Blood tests – a bedside troponin and K+ probably have greatest yield Imaging considerations – again low yield Ballarat Grampians Emergency Medicine Training Hub

14. Clinical cases to demonstrate 19 year old university student Has been up late drinking on Saturday night Wakes up Sunday morning to the sound of his mobile phone Gets up out of bed, talks for half a minute, then feels funny and blacks out Housemate hears phone and the fall, and runs into the room, he is coming around quickly Referred by GP for ED assessment ECG normal Does he require further assessment and management? Ballarat Grampians Emergency Medicine Training Hub

15. Clinical caseAnswer The most likely diagnosis is postural hypotension due to dehydration and suddenly getting up. On clinical grounds still worth checking for high risk clinical features on history, and checking the BP now, systolic murmur etc. Ballarat Grampians Emergency Medicine Training Hub

16. ED role is diagnosisor risk stratification. ACEP 2007 recommendations The emergency physician must identify those relatively few patients with life-threatening processes (e.g., dysrhythmias, pulmonary embolism, aortic dissection, subarachnoid hemorrhage, acute coronary syndromes) and those other patients who may benefit from intervention (e.g., patients with bradycardia, medication-induced orthostatic hypotension) ie - look for evidence of high risk of cardiovascular event or death Ballarat Grampians Emergency Medicine Training Hub

17. History - risk stratification Clear low risk – vasovagal (define), cough/micturition syncope High risk = mainly cardiac stuff: • Exertional, recurrent, recumbent • Cardiac history • Family history (inc. sudden death, deafness) General medical (eg.DM - silent cardiac) AGE >65 years Ballarat Grampians Emergency Medicine Training Hub

18. Diagnostic Testing • ECG: diagnostic in < 5% • Continuous cardiac monitoring: predictors of arrhythmia in 72 monitor – initial abnormal ECG, male sex, age > 65, history of heart disease Ballarat Grampians Emergency Medicine Training Hub

19. Image gallery – ECGs The following is a collection of ECG’s to file away and remember They are generally rare and unexpected but recognition could save lives The other key thing to spot is evidence if ischaemia, including ‘old’ changes, they are more high risk than a NORMAL ECG Ballarat Grampians Emergency Medicine Training Hub

20. ECG changes in hyperK+ Ballarat Grampians Emergency Medicine Training Hub

21. Brugada’s pearlsDo I need to know this? Yes Coved STelev V1-V3 &/- RBBB Associated ventricular arrhythmias Genetic problem with ion channels Overlaps with RVOT problems ECG changes fluctuate and are inducible Treated with AICD (implantable cardiac defibrillator) Ballarat Grampians Emergency Medicine Training Hub

22. Brugada syndrome ECG’s Ballarat Grampians Emergency Medicine Training Hub

23. Wellen’s syndromeDo I need to know this? Yes An ECG pattern of inverted T waves or biphasic T waves (&/- minor ST segments) • Commonest type deep anterior TWI • Less often biphasic ST/T wave anterior leads • Without Q waves & major ST height changes Often occurs ONLY in painfree intervals! Associated with proximal LAD coronary lesions High risk of sudden death, should go directly to angiography due to risk of provocation testing Ballarat Grampians Emergency Medicine Training Hub

24. Wellen’s Ballarat Grampians Emergency Medicine Training Hub

25. What is the diagnosis? Ballarat Grampians Emergency Medicine Training Hub

26. Prolonged QT Ballarat Grampians Emergency Medicine Training Hub

27. Prolonged QT pearls Associated with death from torsades Congenital (+/- deafness) and drugs Ballarat Grampians Emergency Medicine Training Hub

28. Polymorphic VT Can be with or without long QT Torsades de Points means with long QT Treatment is different: • Mg2+ in addition to ACLS (recurs) in Torsades Otherwise treat as VT Ballarat Grampians Emergency Medicine Training Hub

29. Poly- versus monomorphic VT Ballarat Grampians Emergency Medicine Training Hub

30. Polymorphic VT versus coarse VF Ballarat Grampians Emergency Medicine Training Hub

31. What is the diagnosis?This person has frequent faints. Now normal physical exam. Ballarat Grampians Emergency Medicine Training Hub

32. WPW Ballarat Grampians Emergency Medicine Training Hub

33. WPW AF Ballarat Grampians Emergency Medicine Training Hub

34. WPW pearls Common(ish) Associated with RAF, VF, VT Key is avoiding ABCD drugs • Adenosine • Beta blockers • Calcium channel blockers • Digoxin Electricity is safe Ballarat Grampians Emergency Medicine Training Hub

35. Disposition – admit or discharge Admit anyone who has a problem worse than syncope High risk factors mainly based on history Use of decision rules for everyone left over? Our institution has a clinical pathway for the SSU for this condition. Ballarat Grampians Emergency Medicine Training Hub

36. The evidence… This is an ongoing field of work The San Francisco Syncope Rule showed some promise, was validated internally but didn’t do well when externally validated • Principles still seem sound There is a newer BRACES rule from the ROSE study in the UK Ballarat Grampians Emergency Medicine Training Hub

37. The evidence varies a little • Diagnostic rate of 20-50% in the ER • Definitive diagnosis in 15-30% of inpatients after thorough work-up • Framingham Heart Study reported 822 episodes of syncope in 7814 patients over 17 year period1: • Vasovagal (21%) • Cardiac (10%) • Orthostatic (9%) • Unknown (37%) Ballarat Grampians Emergency Medicine Training Hub

38. San Francisco Syncope Rule - 1 Abnormal ECG History of CCF Haematocrit < 30 SOB hypotension Ballarat Grampians Emergency Medicine Training Hub

39. SFSR - 2 Predicts short-term (<1/52) bad outcomes Sensitivity thought to be approach 96% Several validations, some NOT good “not good enough to replace common sense” Ballarat Grampians Emergency Medicine Training Hub

40. San Francisco Syncope Study • 684 patients with syncope • Adverse events recorded at 7 days • 0 factors considered low risk • Sensitivity 86%, Specificity 49% • C – CHF • H – Hematocrit < 30% • E – abnormal EKG (new changes or nonsinus rhythm) • S – systolic BP < 90 • S – Shortness of breath Ballarat Grampians Emergency Medicine Training Hub

41. The ROSE (Risk stratification Of Syncope in the Emergency Dept.) Reed et al., J. Am. Coll. Cardiology 2010 Derivation and validation 550 pt.s each Good (98.5%) NPV (sens 87.2, spec 65.5) 7.3% serious outcome / death ≤ 1/12 Baseline of 50% admission rate (high!?) Editorial “prevention 149 unnecessary admissions at expense of missing 4 serious outcomes but no deaths per 1000 syncope presentations” Ballarat Grampians Emergency Medicine Training Hub

42. The rule: BRACES mnemonic B = BNP(≥300pg/mL) or brady (≤50) R = rectal +ve for FOB (if ?GI bleed) A = anaemia (<90 g/dL) C = chest pain associated with syncope E = ECG shows Q waves (not lead III) S = saturations (≤ 94% room air) Ballarat Grampians Emergency Medicine Training Hub

43. Application Suggestion is to admit anyone with ≥1 Cost benefit was with reducing admissions but required point of care BNP BNP controversial in ED, even author does NOT advocate it for use in breathlessness (appears to have OUTPT benefit in identifying CCF as cause but this is easier in sicker / ED patients anyway) Excluded from the study was alcohol intoxication, low BSL, trauma, ?stroke Ballarat Grampians Emergency Medicine Training Hub

44. Orthostatics (and IM) • Orthostatic hypotension defined as fall in SBP of 20 mm Hg upon assuming upright position • 5 – 55% of patients with orthostatic hypotension also have other identifiable causes of syncope2 • Asymptomatic orthostatic hypotension found in 40% patients > 70 years old Ballarat Grampians Emergency Medicine Training Hub

45. Summary of learning Be alert if • Exercise induced syncope • Abnormal ECG • Heart failure • Age >65 Take a thorough history, never assume the facts. Ballarat Grampians Emergency Medicine Training Hub

46. Take home message Back clinical gestalt first, history is most important Look for high risk ECG’s Clinical decision rules can aid your memory & improve documentation, & perhaps decision making(?!) but don’t override common sense HIGH RISK CRITERIA Abnormal ECG Older patients Cardiac history • Esp. CCF An opinion from an experienced clinician is useful especially if there is uncertainty Ballarat Grampians Emergency Medicine Training Hub

47. References • Soteriades ES, Evans JC, Larson MG, et al: Incidence and prognosis of syncope. New Engl J Med 347:878, 2002. • Atkins D, Hanusa B, Sefcik T, et al: Syncope and orthostatic hypotension. Am J Med 91:179, 1991. • Martin TP, Hanusa BH, Kapoor WN. Risk stratification of patients with syncope. Ann Emerg Med. 1997;29:459-466. • Colivicchi F, Ammirati F, Melina D, et al. Development and prospective validation of a risk stratification system for patients with syncope in the emergency department: the OESIL risk score. Eur Heart J. 2003;24:811-819. • Quinn JV, Stiell IG, McDermott DA, et al. Derivation of the San Francisco syncope rule to predict patients with short-term serious outcomes. Ann Emerg Med. 2004;43:224-232. 23. Calkins H, Shyr Y, Frumin H, et al. • Serrano LA, Hess EP, Bellolio F, et al. Accuracy and quality of clinical decision rules for syncope in the emergency department: a systematic review and meta-analysis. Ann Emerg Med. 2010;56:362-373. Ballarat Grampians Emergency Medicine Training Hub

48. Further reading Ballarat Grampians Emergency Medicine Training Hub

49. Study Support • Martin et al 19973: • 252 syncope patients • Validated cohort 374 patients • Predictors of arrhythmia or 1-year mortality: • Abnormal EKG • h/o ventricular arrhythmia • h/o CHF • Age > 45 • End point arrhythmia or death at 1 year 0% with 0 risk factors and 27% with 3-4 risk factors Ballarat Grampians Emergency Medicine Training Hub

50. Colivicchi et al 2007 • The Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) score • 270 syncope patients, validated with 328 patient cohort • End point was death at 1 year • Sensitivity 95%, Specificity 31% • Found that age, abnormal EKG, lack of prodrome, h/o cardiovascular disease, and heart failure are all reliable predictors of adverse events at 1 year in syncope patients Ballarat Grampians Emergency Medicine Training Hub