Syncope Priya Victor M.D
Introduction • Syncope is defined as transient loss of consciousness and postural tone • Accounts for 3% of all ER visits and 6% of all hospital admissions • Could be the manifestation of benign neurocardiogenic or the first manifestation of an occult lifethreatening condition
Objective • To determine the utility of various diagnostic tests in the evaluation syncope • CT scans • Echo • EKG • Holter monitor • EEG • Tilt table test
Methods • Retrospective study • 100 patients from the RCRMC ER admissions with a diagnosis of syncope were identified • Chart review was performed with attention to the cause of syncope, investigations and results of further testing.
Other tests • 24 hr holter monitor two were done, both normal. • One adenosine cardiolyte – normal. • One ETT – normal. • Two tilt table test , both were positive for hypotension. • One dobutamine stress test – normal.
Causes of syncope • vasovagal 23 • Orthostatic hypotension 9 • Hypoglycemia 6 • Secondary to medications 3 • Sick sinus syndrome 2 • Symptomatic bradycardia 2 • PSVT 2 • BPV 1 • Iron defi anemia 1 • Seizures 1 • Afib with RVR 1 • Neck mass 1 • Unknown etiology 48
Discussion • Of patients visiting ER with syncope: (Alboni et al JACC 2001;37:1921) Cardiac (often arrhythmia) 23% Neurally mediated 58% Neuro-psychiatric 1% Unexplained 18% • Of patients with cardiac syncope, 24% subsequently develop Sudden Death (Kapoor, Medicine (Baltimore) 1990;69:160)
Approach • Accurate diagnosis of etiology is possible from history, examination, basic lab & ECG in 2/3 of patients. • Of those who require detailed work-up: Clinically targeted: Dx. Reached by work-up in 73% Not targeted: Dx. Reached by work-up in 25% (Sarasin et al Am J Med 2001;111:177) • Work-up depends on duration of symptoms,frequency of attacks, known pre-existing disease, and age of the patient.
Neurologic testing • EEG (Hyperventilation, Sleep-deprived, Nasopharyngeal) • Brain CT / MRI • Carotid Duplex Some test is done in over half pts with syncope Rarely useful, except in very well-selected cases Pires et al. Arch Int Med 2001;161:1889
CONCLUSION • Of all the tests performed, EKG was of greatest yield. • The most common etiology was vasovagal. • Even though vasovagal syncope was a common diagnosis , the tilt table test was only ordered for a minority of patients.
CONCLUSION • Of currently available diagnostic tests, the initial clinical history provides the greatest yield. • A broad range of specialized tests can be performed for patients with syncope whose initial history and physical examination do not provide a diagnosis.