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Syncope and The Older Patient Debra L. Bynum, MD Division of Geriatric Medicine Pretest… 1. The ECG has the greatest value in its (NPV or PPV) in the diagnosis of a cardiac etiology for syncope

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syncope and the older patient

Syncope and The Older Patient

Debra L. Bynum, MD

Division of Geriatric Medicine

pretest
Pretest…
  • 1. The ECG has the greatest value in its (NPV or PPV) in the diagnosis of a cardiac etiology for syncope
  • 2. History: 75 year old man reports presyncopal symptoms that occur while he is driving backwards out of his driveway in the morning. This suggests …
  • 3. History: an 80 year old man reports an episode of syncope that occurred after doing arm exercises for a rotator cuff injury. This suggest…
  • 4. The only independent predictor of a cardiac etiology of syncope is a past history of …
  • 5. ____ is a neurodegenerative disease characterized by profound autonomic insufficiency and parkinsonian features on exam
  • 6. An 82 year old man presents with postural hypotension, an idiopathic peripheral neuropathy, significant proteinuria and your attending orders a rectal biopsy to look for____
  • 7. Name 3 causes of “situational syncope”
  • 8. Older patients are more likely to have positive a. tilt table tests b. carotid sinus massage c. orthostatic hypotension d. all of the above
pretest bonus question
Pretest: bonus question
  • Sudden cardiac death in young men (originally described in young asian men) associated with this sign on EKG is known as what syndrome?
syncope definition
Syncope: Definition
  • Sudden and temporary loss of consciousness with inability to maintain postural tone, followed by spontaneous recovery
causes of syncope
Causes of Syncope
  • Neurally Mediated (up to 58% in some series)
  • Orthostatic/postural
  • Cardiac arrhythmia (20-25%)
  • Structural cardiac or pulmonary causes
  • Cerebrovascular or psychiatric (1%)
  • Unknown (18-30%)
syncope in the elderly
Syncope in the Elderly
  • Usually multifactorial
  • Often confounded by findings (orthostasis and carotid hypersensitivity common and may be found and yet not be the cause…)
  • Prevalence up to 25% in nursing home population over age 70
  • Higher pretest probability of cardiac disease or arrhythmia
importance of history and pe
Importance of History and PE
  • Up to 70% of patients in prospective studies had probable cause identified based upon history, physical exam and ecg
the history
The History…
  • History of Heart Disease
    • The ONLY independent predictor of cardiac cause (sens 95%, spec 45%)
    • Absence of heart disease up to 97% specific to rule out cardiac etiology (good NPV)
the history9
The History
  • Position
    • Supine: cardiac until proven otherwise
    • Upon sitting/standing: orthostasis
    • Prolonged standing: venous pooling/orthostasis/vasovagal
  • Presyncopal symptoms
    • Presence suggests vasovagal, but does not rule out arrhythmia
    • Lack of suggests arrythmia (up to 65% with sudden syncope)
  • Dyspnea (Pulmonary embolus)
  • Focal neurologic symptoms (TIA, seizure)
  • Seizure like activity (including loss of bowel and bladder control, tongue bite, postictal state)
the history10
The history…

Recovery period

    • Instant: arrythmia
    • Feeling hot and nauseated: vasovagal
    • Confusion/lethargy: postictal
  • Situational syncope (vasovagal)
    • Cough
    • Swallow (cold liquid)
    • Micturition (urination)
    • Defecation
  • Exertional
    • Ventricular tachyarrhythmia
    • Aortic stenosis or HOCM
    • Pulmonary Hypertension
the history11
The history…
  • Prior “faint” 1-4 years prior suggest vasovagal
  • Age
  • Medications
    • Tricyclic antidepressants
    • Nitrates
    • Alpha adrenergic antagonists
    • Diuretics
  • Injury (facial suggests arrhythmia)
  • Postprandial (vagally mediated)
specific causes and treatment options for syncope
Specific Causes and Treatment Options for Syncope
  • Postural Hypotension
    • Drop in systolic blood pressure of over 20
    • Medications
    • Autonomic Insufficiency
      • No reflex tachycardia
      • Shy-Drager (multiple systems atrophy)
      • Primary autonomic failure
      • Parkinson’s Disease
      • Diabetes
      • Aging
      • Amyloid
    • Volume Loss
      • Dehydration
      • Blood loss
autonomic insufficiency and orthostatic hypotension
Autonomic Insufficiency and Orthostatic Hypotension
  • Treatment Options
    • Review of medications
    • Avoid volume depletion
    • Arising slowly
    • Tensing crossed legs while standing
    • Dorsiflex feet or handgrip prior to standing
    • Thigh high Jobst stockings (decreases venous pooling)
    • Avoid prolonged standing (venous pooling)
    • Increased salt diet
    • Smaller meals to avoid postprandial drop in BP
    • Fludrocortisone
    • Midodrine (alpha 1 adrenergic agonist)
    • Phenylephrine (not usually used in older patients)
    • Fluoxetine
mechanical cardiac causes
Mechanical Cardiac Causes
  • Obstruction to LV outflow
    • Aortic Stenosis
    • HOCM
    • Left atrial myxoma
    • Mitral Stenosis
  • Obstruction to pulmonic flow
    • Pulmonic stenosis
    • Pulmonary HTN
    • PE (can also have vasovagal type syncope associated with smaller PEs)
    • Right atrial myxoma
other mechanical cardiac causes
Other Mechanical Cardiac Causes
  • Large MI with LV dysfunction
  • CHF
  • Tamponade
  • Aortic dissection
cardiac arrhythmias
Cardiac Arrhythmias
  • Bradycardia
    • Sick sinus syndrome
    • 2nd or 3rd degree AV block
    • Pacemaker malfunction
  • Tachycardia
    • Ventricular tachycardia
    • Ventricular fibrillation
    • SVT
    • If you see atrial fibrillation, think sick sinus syndrome as potential cause of syncope…
brugada syndrome
Brugada Syndrome
  • Triad
    • RBBB pattern in right precordial leads
    • Transient/persistent ST elevation in v1-v3
    • Sudden cardiac death
  • Structurally normal heart
  • Association with young and healthy men from southeast asia who present with sudden cardiac death
  • Brugada sign may be asymptomatic
  • High risk of sudden cardiac death in those who have syncope or family history of sudden death (Indication for AICD based upon observational data)
implantable cardioverter defribrillator guidelines
Implantable Cardioverter-Defribrillator Guidelines
  • AICD indicated for patients with spontaneous Vtach with underlying heart disease or in patients with normal heart when vtach not amenable to other treatments
aicd guidelines
AICD guidelines
  • Ischemic Cardiomyopathy
    • LVEF <30%
    • At least 1 month after MI and 3 months after revascularization
    • MADIT-II trial
      • Multicenter Automatic Defibrillator Implantation Trial
      • 5.6% ARR in mortality over 4 years
    • Results support prophylactic AICD, but not considered cost wise
    • Based upon subset analysis, Current recommendation in those with QRS >120 ms
    • Unclear result: those with ICDs had 5% absolute increased risk of hospitalization for CHF (19% vs 14%): ?artifact, ?due to living longer?, ?detrimental
aicd guidelines21
AICD guidelines…
  • Syncope in patients with advanced structural heart disease
    • High risk of sudden cardiac death
  • Inducible Vtach with structural heart disease
  • Inducible Vtach with normal heart that is not amenable to ablation therapy
subclavian steal syndrome
Subclavian Steal Syndrome
  • Proximal subclavian artery stenosis
  • Decreased blood flow to distal subclavian artery worsened with exertion of arm
  • Blood from vertebral artery on opposite side goes to basilar artery and then down ipsilateral vertebral artery, away from brainstem, to serve as collateral for arm
  • Usually asymptomatic
  • Atherosclerosis
  • Symptoms of vertebrobasilar insufficiency (dizziness, vertigo, diplopia, nystagmus)
  • Rare to have permanent neurological deficits
  • Diagnosis with dopplers, MRA
  • Treatment: surgical revascularization, stents
cerebrovascular disease
Cerebrovascular Disease
  • Less common cause of true syncope
  • Vertebrobasilar disease (presyncope)
  • Drop Attacks
vasovagal neurocardiogenic syncope
Vasovagal/Neurocardiogenic syncope
  • Situational Syncope
    • Micturition
    • Defecation
    • Cough
    • Swallow
  • Recurrent Neurocardiogenic Syncope
  • Posprandial
  • The FAINT
vasovagal syncope
Vasovagal Syncope
  • Presyncopal symptoms
  • Setting (procedure, pain, anxiety)
  • Prior history
neurally mediated syncope
Neurally Mediated Syncope
  • Cardiac sensory receptors in LV stimulated by stretch
  • Increased neural discharge to vasomotor center in medulla
  • Increased parasympathetic tone and decreased sympathetic activity
  • Sudden bradycardia and hypotension
recurrent neurocardiogenic syncope
Recurrent Neurocardiogenic Syncope
  • Upright posture lead to pooling of blood in lower extremities
  • Decreased venous return
  • Normal response: reflex tachycardia and forceful LV contraction and vasoconstriction
  • Susceptible individuals: activation of mechanoreceptors triggers reflex bradycardia and hypotension
  • Response triggered by forceful LV contraction with prolonged standing or with increased catecholamines (anxiety, fear, panic, pain)
treatment of recurrent neurocardiogenic syncope
Treatment of Recurrent Neurocardiogenic Syncope
  • Medications
    • Paroxetine
      • Only agent shown effective in RCT
    • Midodrine
      • Alpha adrenergic agonist
      • Small studies
    • Fludrocortisone
      • No good study
    • Beta blockers
      • Often used, mixed evidence in studies
pacemakers in the treatment of recurrent neurocardiogenic syncope
Pacemakers in the treatment of Recurrent Neurocardiogenic Syncope
  • 3 large RCTs of permanent pacing
    • North American Vasovagal Pacemaker Study (VPS-1)
      • Patients with over 6 episodes, positive tilt table test with significant bradycardia
      • Significant decrease in recurrence with pacer (HR .087)
    • Vasovagal Syncope International Study
      • 5% recurrence with pacemaker vs 61% without (19 patients)
    • Syncope Diagnosis and Treatment Study
      • Pacemaker vs atenolol
      • 93 patients: 4.3% recurrence vs 26%
pacemakers and neurocardiogenic syncope
Pacemakers and neurocardiogenic syncope:
  • Problems with trials…
    • Small numbers of patients
    • Not blinded
    • Highly selected patients
      • Patients had profound bradycardia on tilt table testing and multiple episodes
pacers and neurocardiogenic syncope
Pacers and neurocardiogenic syncope…
  • Bottom line:
    • May benefit patients with recurrent episodes of clear neurally mediated syncope, associated with significant bradycardic response, who have a decreased QOL otherwise (injuries, driving, etc)
carotid sinus hypersensitivity
Carotid Sinus Hypersensitivity
  • ?Role of Carotid Sinus Massage
    • Some recommend if no bruits, recent MI, cva or history of vtach
    • ?monitor
    • Positive response: 3 sec pause
    • In literature, but most cardiologists would not recommend
  • High yield of carotid massage in elderly (up to 40% over the age of 75 may have a positive response), but not specific in identifying this as the cause of syncope (PPV not known)
  • History: syncope/presyncope with turning neck, backing up in car, wearing tight collar
evaluation of syncope
Evaluation of Syncope
  • When a cause of syncope is identified, history and physical lead to etiology in up to 85% cases
  • The only independent predictor of a cardiac cause of syncope is the presence of underlying heart disease (95% sens, only 45% spec)
orthostasis
Orthostasis
  • May be confounder in older patients
  • Up to 25% of older patients may have orthostasis when tested, the presence of orthostasis may be true, true and unrelated…
the ecg
The ECG
  • Prolonged QT
  • Bradycardia, AVN disease, MI, HOCM, Brugada
  • Only 2-10% will have diagnostic abnormality
  • Up to 50% of patients with syncope have abnormal EKG
  • Greatest use in NPV (negative predictive value) of NORMAL ECG
the holter monitor
The Holter Monitor
  • 24-48 hours continuous ECG
  • No added yield with 72 hours
  • Low yield unless frequent symptoms
  • Up to 70% of Holter studies negative for diagnosis
  • One series: only 5% of studies had arrhythmia that correlated with symptoms
  • Probably good NPV if symptoms documented with benign rhythm
event or loop monitors
Event or Loop Monitors
  • Higher yield than holter (up to 55% positive yield of symptom-arrhythmia correlation in some series)
  • Problem with patient education and ability to activate monitor correctly (25% of patients have difficulty)
  • May be especially problematic in the very elderly or those with dementia
implantable loop recorder
Implantable Loop Recorder
  • Prolonged monitoring for those with syncope of unclear etiology despite workup, especially for those in whom cardiac etiology is suspected
  • Several small studies suggest that in very selected patients, may increase yield of diagnosis to almost 85%
other cardiac tests
Other Cardiac Tests
  • Echo
  • Exercise or Functional Tests
  • EP studies
  • Most useful when history or physical suggests specific further testing to be done…
tilt table testing
Tilt Table Testing…
  • Passive or Isoproterenol
  • Test: patient held in upright position at 40-90 degrees and observed for symptoms and hypotension or bradycardia
  • Passive testing: sensitivity of 70%, specificity of 90-100%
  • Isoproterenol: only 55% specificity
  • Overall little to add to history and PE; lack of sensitivity with passive testing and lack of specificity with induced testing limits usefulness of test…
lab tests
Lab tests…
  • The basics (anemia)
  • ?BNP: some studies report usefulness as a marker for cardiac cause of syncope: sensitivity of 82% and specificity of 92%, Likelihood ratios of pos and neg tests probably not more useful than pretest probability of underlying heart disease based upon history and physical exam
  • CK, MB and Troponins
    • More useful if positive (greater PPV) than neg
    • One series: up to 10% nursing home patients presenting with syncope had positive enzymes…
the least useful tests
The Least Useful Tests…
  • CT head with negative neurological exam
  • EEG with no neurological symptoms
  • Carotid Artery Dopplers (useful for evaluation of CVA or TIA, not useful for evaluation of syncope without vertebrobasilar symptoms…)
the older patient
The Older Patient
  • Positive tests that are more common in the elderly and not necessarily the cause of the syncope:
    • Orthostasis
    • Positive carotid massage
    • Positive tilt table testing
      • Up to 54% of older patients with syncope may have positive test…
      • Positive test in 10% of asymptomatic elderly!
slide44

Algorithm for diagnosing syncope

Linzer, M. et. al. Ann Intern Med 1997;127:76-86

slide45

Summary of Charges for Diagnostic Tests in Syncope*

Linzer, M. et. al. Ann Intern Med 1997;127:76-86

summary
Summary
  • Syncope in the older patient usually multifactorial
  • Tailor tests based upon history and physical exam
  • Elderly more likely to have positive tests that may be confounders…
  • Elderly more likely to have underlying heart disease and higher pretest probability of a cardiac etiology
  • Use algorithms in older, complicated patients with great caution!!!
back to the pretest
Back to the Pretest…
  • 1. The ECG has the greatest value in its (NPV or PPV) in the diagnosis of a cardiac etiology for syncope
  • 2. History: 75 year old man reports presyncopal symptoms that occur while he is driving backwards out of his driveway in the morning. This suggests …
  • 3. History: an 80 year old man reports an episode of syncope that occurred after doing arm exercises for a rotator cuff injury. This suggest…
  • 4. The only independent predictor of a cardiac etiology of syncope is a past history of …
  • 5. ____ is a neurodegenerative disease characterized by profound autonomic insufficiency and parkinsonian features on exam
  • 6. An 82 year old man presents with postural hypotension, an idiopathic peripheral neuropathy, significant proteinuria and your attending orders a rectal biopsy to look for____
  • 7. Name 3 causes of “situational syncope”
  • 8. Older patients are more likely to have positive a. tilt table tests b. carotid sinus massage c. orthostatic hypotension d. all of the above
answers to pretest
Answers to Pretest…
  • 1. NPV
  • 2. Carotid Hypersensitivity
  • 3. Subclavian steal syndrome
  • 4. Cardiac history
  • 5. Multiple Systems Atrophy (shy-drager)
  • 6. amyloid
  • 7. micturition, defecation, cough, swallow
  • 8. all of the above
  • 9. bonus: brugada syndrome
selected references
Selected References
  • Benditt DG, VanDjjk JG, Sutton R. Syncope: Curr Prob Cardiol 2004; 29(4): 152-229
  • Epstein AE. An update on implantable cardioverter-defibrillator guidelines. Curr Opin Cardiology 2004; 19(1): 23-25
  • Littman L et al. Brugada syndrome and Brugada sign. Am Heart J 2003; 145(5): 768-778
  • Raj S, Sheldon RS. Role of pacemaker in treating neurocardiogenic syncope. Curr Opinion Cardiol 2003; 18: 47-52
  • Gregoratos G, Cheitlin MD, Conill A. ACC/AHA guidelines for implantation of cardiac pacemakers and antiarrthythmia devices: executive summary: a report of the American College of Cardiology/Am Heart Assoc Task Force on Practice Guidelines. Circulation. 1998; 97: 1325-1335
  • Connolly SJ et al. The North American Vasovagal Pacemaker Study. J Am Coll Cardiol 1999; 33: 16-20
  • DiGirolamo et al. Effects of paroxetine on refractory vasovagal syncope. J Am Coll Cardiol 1999; 33: 1227-30
  • Sutton R et al. Dual chamber pacing in the treatment of neurally mediated tilt-positive cardioinhibitory syncope (VASIS). Circulation 2000; 102: 294-299
selected references50
Selected References…
  • Krahn Ad et al. Use of the implantable loop recorder in evaluation of patients with unexplained syncope
  • Kapoor WN. Current evaluation and management of syncope. Circulation 2002; 106: 1606
  • Alboni P et al. Diagnostic Value of history in patients with syncope. J Am Coll Cardiol 2001; 37: 1921
  • Kapoor et al. Evaluation and outcome of patients with syncope. Medicine 1990; 69: 160
  • Linzer et al. Diagnosing syncope: part I. Ann Int med 1997; 126:989
  • Linzer et al. Diagnosing syncope: part II. Ann Int Med 1997; 127: 76