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Syncope. 1. Definitions 2. Epidemiology 3. Etiology 4. Diagnostic Strategy 5. Disposition. James L. Wofford, MD, MS. Syncope - Quick take. Dangerous, disabling, and difficult to dx Symptom, not a diagnosis Rarely witnessed The emergency is already over

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syncope
Syncope

1. Definitions

2. Epidemiology

3. Etiology

4. Diagnostic Strategy

5. Disposition

  • James L. Wofford, MD, MS
syncope quick take
Syncope - Quick take
  • Dangerous, disabling, and difficult to dx
  • Symptom, not a diagnosis
  • Rarely witnessed
  • The emergency is already over
  • No reference or gold standards for many tests
syncope definitions
Syncope - Definitions
  • ACP 1997 - Transient loss of consciousness (LOC) with loss of postural tone, from which recovery is spontaneous
  • ACEP 2001- Sudden, transient LOC with inability to maintain postural tone and is distinct from seizure, coma, vertigo, hypoglycemia and other states of altered consciousness
  • ESC 2001 - Transient, self limited LOC with a relatively rapid onset and usually leading to falling; the subsequent recovery is spontaneous, complete, and usually prompt.
syncope epidemiology
Syncope - Epidemiology
  • 3% of general population/yr
    • - Increases with age
    • - 1-6% of all hospitalizations/ED visits
  • 20% of pts. have recurrence within 1 yr
    • - 6% of recurrences assd with MVAs/fx
  • Increased mortality related to cardiac co-morbidity
slide5

Syncope - Epidemiology

  • Cardiac Syncope
    • 5 year mortality - 50%
    • 1 year mortality - 30%
  • Noncardiac Syncope
    • 1 year mortality - <6%
  • Unexplained Syncope
    • 1 year mortality - <6%
syncope indications for hospitalization
Syncope - Indications for Hospitalization
  • Indicated
    • -Hx of CAD, CHF, ventricular arrhythmia
    • -Accompanying sx of chest pain
    • -Physical signs of significant valve dz, CHF, stroke, or focal neuro dz
    • -EKG - ischemia, arrhythmia, QT problems, BBB
  • Often indicated
    • -Sudden LOC with injury, rapid heart action exertional syncope
    • -Frequent spells, suspicion of CAD or arrythmia, meds suspicious of Torsades
    • -Moderate-to-severe orthostatic hypotension
is it really syncope
Is it really syncope?
  • dizziness
  • presyncope
  • vertigo
  • disequilibrium
  • lightheadedness
  • weak and dizzies
  • done fell out

drop attack

found down

is it really syncope dizziness
Is it really syncope? Dizziness
  • Much more common than syncope
    • - 30% annual incidence in the elderly
    • - 1% of all clinic visits
  • Good prognosis
    • - 28% improve by 2 weeks
    • - majority improve by 1 year
  • Tests for syncope not often helpful
  • 80% of elderly have no specific identifiable cause
is it really syncope9
Is it really syncope?

Seizure

  • Seizure - blue face (not pale), frothing, tongue biting, disorientation after event, aching muscles, LOC >5 min, slow return to nl mental statusSyncope - nausea or sweating before event, oriented after the event
  • PROBLEMS- Injury, tongue-biting, incontinence not useful in discriminating "fit" from "faint" - Sz activity in assn with LOC does not define a seizure as its cause (convulsive syncope)
slide10

Is it really syncope?

Stroke

  • 6% of pts with TIA\stroke have LOC
  • posterior circulation - supplies the RAS - drop attacks
  • anterior circulation - would require bilateral compromise, only theoretically possible
  • need focal neuro sx\signs to use TIA as dx
case 1
Case #1
  • 75yoWF admitted for syncopal episode. Brought to ED by daughter who reports declining functional status. Poor historian but claims no problems with palpitations, chest pain, SOB. Chief complaint - chronic low back and knee pain.
  • PMHX - osteoarthitis, osteoporosis - multiple vertebral fractures, HTN, mild cognitive impairment
  • MEDS Roxicodone BID, prn Vicodin, Xanax 0.5 TID, Fosamax 10 mg qD, Prempro qD, HCTZ 25 qD, amlodipine 5 qd
  • PE remarkable for weight 86#, normal BP, 2\6 SEM at LUSB, multiple bruises over forearms, inability to attend to task of answering questions.
slide12

Syncope - Mechanisms

  • global cerebral hypoperfusion
  • interruption of sympathetic outflow
  • increased vagal tone
  • other mechanisms - edema, cerebral autoregulation, central serotonin pathways

The trigger for the switch in autonomic response remains one of the unresolved mysteries in cardiovascular physiology.

Hainsworth. Syncope: what is the trigger? Heart 2003;89:123-124

syncope etiology
Syncope - Etiology
  • Old News- Diagnostic criteria not firmly established- Studies are poorly done, old and retrospective - selection bias - lack of diagnostic standardization
  • Recent reviewsAnnals 1997, N Engl J Med 1999
  • New prospective studies
  • New Guidelines - European Task Force, 2001
slide18

Syncope - Etiology

  • Reflex mediated - 40%
  • Unexplained - 25%
  • Cardiac - 15%
  • Others - 20%
    • Hypoglycemia
    • Orthostatic hypotension
    • Medications
    • Psychiatric
    • Neurologic
slide19

Vasovagal

Situational

Other

Carotid sinus

Neuralgia

Syncope - Etiology

  • Reflex mediated - 40%
  • Unexplained - 25%
  • Cardiac - 15%
  • Others - 20%
    • Metabolic
    • Orthostatic hypotension
    • Medications
    • Psychiatric
    • Neurologic
mass fainting at rock concerts nejm 1994 332 1721
Mass Fainting at Rock ConcertsNEJM 1994;332;1721
  • METHODS - Infirmary interview of 40 of the 4000 people who fainted during a concert by New Kids on the Block
slide21

Mass Fainting at Rock Concerts

NEJM 1994;332;1721

  • - All were girls between 11-17 YO- 40% reported having lost consciousness- Many still breathing rapidly backstage during interview
  • Reported combination provoking factors - sleeplessness during previous night - fasting since early AM while waiting in line - long periods of standing - hyperventilation (vasoconstriction) - Valsalva-like pressure
  • Interpretation - ROCK-CONCERT SYNCOPE - multifactorial pathophysiology- Preventive guidelines - sleep, sit, eat, keep cool, stay out of the crowd
slide22

Vasovagal

Situational

Other

Carotid sinus

Neuralgia

Syncope - Etiology

  • Reflex mediated - 40%
  • Unexplained - 25%
  • Cardiac - 15%
  • Others - 20%
    • Metabolic
    • Orthostatic hypotension
    • Medications
    • Psychiatric
    • Neurologic
slide23

Case #2

  • A 72-year-old man with recurrent dizziness, confusion, and syncope reported that cold, carbonated beverages caused him to feel strange, dizzy, and confused and might have triggered several episodes over a one-year study period. A carotid Doppler study, 24-hour Holter monitor, cranial MRI scan, CCT scan, and echocardiogram were unremarkable. An EEG showed diffuse slowing. Phenytoin was given but provided no improvement.
slide24

Case #2

Another internist evaluated the patient's condition and ordered a ETT and another MRI scan, which were negative. A cardiologist was consulted, and the results of a tilt-table test and coronary angiography were normal. After this evaluation, the patient drank a carbonated beverage while driving and wrecked his car.

slide25

Case #2

- A Pepsi Challenge

New England J Med 1999;340:342

The patient was referred to me for further evaluation, and he gave the same history. Because the episodes were initiated reproducibly with cold, carbonated beverages, a can of Pepsi was given to the patient to drink while he was being monitored with an electrocardiograph. Abrupt bradycardia and hypotension developed, along with the patient's usual symptoms. Carotid-sinus massage was negative.

slide28

Vasovagal

Situational

Other

Carotid sinus

Neuralgia

Syncope - Etiology

  • Reflex mediated - 40%
  • Unexplained - 20%
  • Cardiac - 20%
  • Others - 20%
    • Metabolic
    • Orthostatic hypotension
    • Medications
    • Psychiatric
    • Neurologic
syncope diagnostic strategy
Syncope – Diagnostic Strategy
  • History
    • Presyncopal
      • Positional, activities (exertional?), warning sx (palpitations), environment
    • Syncopal (witness)
      • Duration, seizure activity, skin color, diaphoresis, injury
    • Postsyncopal
      • Time to recovery
    • Past episodes , frequency of syncope
    • Past cardiac and other medical history
    • Medications
syncope diagnostic strategy30
Syncope - Diagnostic Strategy
  • Alboni et al, 2001
    • Best predictors of a cardiac cause
      • Patients with certain or suspected heart disease, syncope in supine position or during effort, blurred vision, convulsive synope
    • Only hx of heart disease is an independent predictor of cardiac cause of syncope (sens 95%, spec 45%)
medications associated with syncope
Medications Associated with Syncope

Syncope - Diagnostic Strategy

  • AntidepressantsAntiarrhythmicsAntihypertensivesBeta blockersCa blockersCardiac glycosidesDiuretics

Nitrates

Phenothiazines

Recreational drugs

Alcohol

Cocaine

Marijuana

Hypoglycemics

slide32

Syncope - Diagnostic Strategy

  • Physical examination
    • complete
    • orthostatic hypotension - systolic change of 20 mm Hg - sitting BP unreliable
    • cardiovascular - difference in BP between arm
    • guiac
    • neurologic
    • carotid sinus**
slide37

Syncope - Diagnostic Strategy

  • ECG
    • yield for specific diagnosis low (5%)
    • risk free and relatively inexpensive.
    • abnormalities (BBB, previous MI, nonsustained VT) guide further evaluation
    • recommended in almost all patients
slide38

Syncope - Diagnostic Strategy

  • Hx and PE and EKG

Diagnostic

Suggestive

Unexplained

slide39

Syncope - Diagnostic Strategy

50%

50%

  • Hx and PE and EKG

Diagnostic

Suggestive

Unexplained

slide40

Syncope - Diagnostic Strategy

  • Hx and PE and EKG

Diagnostic

Suggestive

Unexplained

Laboratory Tests

- Routine use not recommended

- Should be done only if specifically suggested by H&P.

- Pregnancy testing should be considered in women of child-bearing age, especially in those for whom tilt-table or EP testing is being considered.

slide41

Syncope - Diagnostic Strategy

  • Hx and PE and EKG

Diagnostic

Suggestive

Unexplained

Neurologic testing

- EEG - not useful unless seizures

- Brain imaging - not useful unless focality

- Neurovascular studies

- no studies

- may be useful if bruits, or hx suggests

vertebrobasilar insufficiency

slide42

Syncope - Diagnostic Strategy

  • Hx and PE and EKG

Diagnostic

Suggestive

Unexplained

Echocardiography

- Recommended in patients when cardiac disease is suspected

- Only makes the diagnosis in severe AS and atrial myxoma

- Findings may be useful to stratify the risk of cardiac substrate

slide43

Syncope - Diagnostic Strategy

  • Hx and PE and EKG

Diagnostic

Suggestive

Unexplained

Examples

vasovagal

situational

orthostatic hypotension

polypharmacy in the elderly

vasovagal syncope
Vasovagal Syncope
  • - most common cause of syncope - confusing terms (Bezold-Jarisch reflex, cardioinhibitory, neurocardiogenic, neurally mediated)- compensatory increase in sympathetic tone interrupted - mediated by excessive activation of cardiac mechanoreceptors that have connections to brainstem
  • - appropriate setting (fear, injury, illness, sight of blood, etc.)- upright posture- warning period of progressive symptoms (warmth, lightheadedness, nausea, roaring in ears, dimming vision)- prompt recovery (seconds) (beware of the well meaning bystander)
vasovagal syncope45
Vasovagal Syncope
  • Graham LA, Kenney RA. Clinical characteristics of patients with vasovagal reactions presenting as unexplained syncope. Europace 2001;3:141-46
malignant vasovagal syncope
Malignant Vasovagal Syncope
  • A 62-year-old man without significant medical history presented to his doctor with repeated episodes of syncope. The episodes were always associated with micturition (often at night) and had caused falls resulting in head injury. His wife was particularly concerned, noting that he became apneic while sleeping. He was diagnosed with sleep apnea. A 24-hour Holter monitor was obtained as part of the syncope evaluation. While wearing the monitor, he awoke in a panic, feeling that something was very wrong, and he came directly to the emergency room. He was evaluated in the emergency room and was told he was fine. The patient insisted, however, that the Holter monitor be reviewed before he left the hospital. The Holter monitor displayed 8 asystolic pauses, including 1 pause of 21 seconds and another of 35 seconds, at which point he awoke abruptly (Figure). The etiology was felt to be malignant vasovagal syncope. On the basis of these results, he was admitted to the hospital and a dual-chamber pacemaker was placed. At 18 months of follow-up, the patient reports no more episodes of micturition syncope. He uses the pacemaker only 2% of the time. He has greater energy, and his wife reports that the sleep apnea is gone.
slide47

Syncope - Diagnostic Strategy

50%

  • Hx and PE and EKG

Diagnostic

Suggestive

Unexplained

Examples

vasovagal

situational

orthostatic hypotension

polypharmacy in the elderly

slide48

Syncope - Diagnostic Strategy

50%

  • Hx and PE and EKG

Diagnostic

Suggestive

Unexplained

CNS disease

EEG

CCT, MRI

Cerebral flow st.

Angiography

Carotid sinus syncope

Carotid massage

Reduced cardiac output

Echocardiogram

Cardiac cath

CPK-MB, CCU admission

Spiral CT scan

Pulmonary arteriogram

slide49

Syncope - Diagnostic Strategy

50%

  • Hx and PE and EKG

Diagnostic

Suggestive

Unexplained

slide50

Syncope - Diagnostic Strategy

50%

  • Hx and PE and EKG

Diagnostic

Suggestive

Unexplained

Organic heart disease

or Abnormal EKG

No suspected

heart disease

Age >60

slide51

Syncope - Diagnostic Strategy

50%

  • Hx and PE and EKG

Diagnostic

Suggestive

Unexplained

Unexplained

Organic heart disease

or Abnormal EKG

No suspected

heart disease

Age >60

Cardiac Evaluation

Echocardiogram

Stress test

Rhythm monitoring

slide52

Syncope - Diagnostic Strategy

50%

  • Hx and PE and EKG

Diagnostic

Suggestive

Unexplained

Organic heart disease

or Abnormal EKG

No suspected

heart disease

Age >60

Cardiac Evaluation

Echocardiogram

Stress test

Rhythm monitoring

Consider

- postprandial

- medications

- carotid sinus syndrome

carotid sinus syndrome
Carotid Sinus Syndrome
  • assd with - pathologic abnormalities of the neck - meds - digoxin, alphamethyldopa, propanolol- two types - cardioinhibitory - vasodepressor- suspect in elderly patients (tight collar, shaving, head turning)
carotid sinus syndrome54
Carotid Sinus Syndrome
  • - examine for carotid bruits- estabish venous access and cardiac monitor, with atropine available- with patient supine, massage each carotid 5-10 secs while monitoring HR and BP- positive reponse is asystole of 3 seconds or drop in systolic BP of 50 mmHg- if vasodepressor type is suggested, redo in sitting and standing position with fall protection- nonspecific - 25% of nonsyncopal elderly pts will have a positive response
slide55

Syncope - Diagnostic Strategy

50%

  • Hx and PE and EKG

Diagnostic

Suggestive

Unexplained

Organic heart disease

or Abnormal EKG

No suspected

heart disease

Age >60

Cardiac Evaluation

Echocardiogram

Stress test

Rhythm monitoring

Consider

- postprandial

- medications

- carotid sinus syndrome

slide56

Syncope - Diagnostic Strategy

50%

  • Hx and PE and EKG

Diagnostic

Suggestive

Unexplained

Organic heart disease

or Abnormal EKG

No suspected

heart disease

Age >60

First episode

Frequent

Infrequent

slide57

Syncope - Diagnostic Strategy

  • Hx and PE and EKG

No suspected

heart disease

Unexplained

Frequent

First episode

Infrequent

slide58

Syncope - Diagnostic Strategy

  • Hx and PE and EKG

No suspected

heart disease

Unexplained

Frequent

First episode

Infrequent

STOP

workup

consider

tilt table

psycheval

rhythm monitoring

tilt table testing
Tilt Table testing

Syncope - Diagnostic Strategy

  • Tilt table testing - passive (60 degrees, 45 min) - isoproterenol, nitroglycerin - 50% with unexplained syncope had positive response - 2/3 of responses cardioinhibitory
rhythm monitoring
Rhythm monitoring

Syncope - Diagnostic Strategy

  • Event monitors - highest yield with palpitations and recurrent events - requires a compliant patient
psychiatric causes
Psychiatric causes

Syncope - Diagnostic Strategy

  • Consider when - frequent fainting in young patients - syncope that does not cause injury - many symptoms
  • Hyperventilation maneuver and psychiatric screening instruments recommended. Hyperventilation maneuver - open mouth; slow, deep breaths - 20X/minute for 3 minutes - endpoint - target sx
syncope diagnostic strategy62
Syncope - Diagnostic Strategy
  • Hx and PE and EKG

Diagnostic

Suggestive

Unexplained

Organic heart disease

or Abnormal EKG

No suspected

heart disease

Age >60

First episode

Frequent

Infrequent

consider

tilt table

psycheval

rhythm monitoring

STOP

workup

slide63

Syncope - Diagnostic Strategy

  • Hx and PE and EKG

Diagnostic

Suggestive

Unexplained

the end
THE END
  • VVS
  • Beta blockers falling out of favor
  • Pacemaker not useful
  • Crossed legs maneuver for OH
  • Driving
slide65
47-year-old WM presents to local ED with several episodes of syncope same PM . First syncopal event associated with defecation, but two other episodes of syncope while he was on the floor, that were witnessed by his wife. After third episode, she reported tremor in his right hand and right facial droop. Patient had been having a “viral” syndrome and had not felt well for the previous several days. Old records are not available to me at this time. No hx of chest pain, palpitations or shortness of breath with the event.Past Medical History: Chronic sinusitis controlled with an antihistamineMedications: Allegra 180 q day.Family History: Brother died of a diabetic coma at ten years of age. Father - CABG at age 65, kidney stones.Social History: Statistician who lives in North Wilkesboro with his wife and two children. Normally active in summers, at least with softball.