Effective Management of Syncope 2019

Win K. Shen, MD Mayo Clinic Arizona Cedars 2019

©2018 MFMER | 3743009-2

DISCLOSURE

Relevant Financial Relationship(s) None

Off Label Usage None

©2018 MFMER | 3743009-3

Learning Objectives Effective Management of Syncope

1. Initial evaluation 2. Hospital admission 3. Additional evaluation and diagnosi

• What NOT to do 4. Treatment for vasovagal syncope (ER) 5. Syncope and driving 6. Take home message

©2018 MFMER | 3743009-4

©2018 MFMER | 3743009-5

Syncope: Why Important and When Worry? • A very common “SYMPTOM”:

• Prevalence: 15 – 40% • Annual incidence, up to 7-8% • Recurrence incidence, up to 15%

• Impact on individuals and public health • Physical harm, psycho-social,

medical legal • 1-2.4% of ED visits (> 10 M patients) • High hospital admission • Cost of inpatient eval > 2.5 B/yr

• Potential causes range from benign etiologies to life-threatening conditions resulting in extensive broad-based evaluation

©2018 MFMER | 3743009-6

Syncope: Initial Evaluation

Evaluation as clinically indicated

Transient loss of consciousness

Initial evaluation history, physical examination,

and ECG (Class I)

Suspected syncope

Cause of syncope certain

Yes

No

Risk assessment Cause of syncope uncertain

Treatment Further evaluation

Shen et al, Syncope Guideline, Circ 2017

©2018 MFMER | 3743009-7

History, History, History!! More Often Associated With Cardiac Causes of Syncope

1. Older age (>60 y of age) 3. Presence of known ischemic heart disease, structural heart disease, previous arrhythmias, reduced ventricular function. Male sex 4. Brief prodrome such as palpitations, or sudden loss of consciousness without prodrome 5. Syncope during exertion 6. Syncope in the supine position 7. Low number of syncope episodes (1 or 2) 8. Abnormal cardiac examination 9. Family history of inheritable conditions or premature SCD (<50 y of age) 10. Presence of known congenital heart disease

More Often Associated With Non-cardiac Causes of Syncope 1. Younger age 2. No known cardiac disease 3. Syncope only in the standing position 4. Positional change from supine or sitting to standing 5. Presence of prodrome: nausea, vomiting, feeling warmth 6. Presence of specific triggers: dehydration, pain, distressful stimulus, medical environment 7. Situational triggers: cough, laugh, micturition, defecation, deglutition 8. Frequent recurrence and prolonged history of syncope with similar characteristics

©2018 MFMER | 3743009-8

Hospital Admission (ED)

Syncope initial evaluation

Manage selected pts with suspected

cardiac syncope in outpatient setting

(Class IIb)

Serious medical conditions

present?

Yes

Structured ED observation protocol

for intermediate risk pts

(Class IIa)

Manage presumptive reflex-mediated

syncope in outpatient setting

(Class IIa)

Inpatient evaluation (Class I)

No

Shen et al: AHA/ACC/HRS Syncope Guidelines, Circ 2017

©2018 MFMER | 3743009-9

“Serious Medical Conditions”

Cardiac Arrhythmic Conditions Cardiac or Vascular Non-arrhythmic

Conditions

Non-cardiac Conditions

• Sustained or symptomatic VT • Symptomatic conduction system

disease or Mobitz II or third-degree heart block

• Symptomatic bradycardia or sinus pauses not related to neurally-mediated syncope

• Symptomatic SVT • Pacemaker/ICD malfunction • Inheritable cardiovascular conditions

predisposing to arrhythmias

• Cardiac ischemia • Severe aortic stenosis • Cardiac tamponade • HCM • Severe prosthetic valve

dysfunction • Pulmonary embolism • Aortic dissection • Acute HF • Moderate-to-severe LV

dysfunction

• Severe anemia, gastrointestinal bleed

• Major traumatic injury due to syncope

• Persistent vital sign abnormalities

©2018 MFMER | 3743009-10

Syncope Additional Evaluation and Diagnosis

Syncope additional evaluation and diagnosis

Initial evaluation: History, physical exam, ECG

(Class I) Initial evaluation

clear

No additional evaluation needed*

Targeted blood testing

(Class IIa)†

Initial evaluation suggests

neurogenic OH

Referral for autonomic evaluation (Class IIa)†

Initial evaluation suggests

reflex syncope

Tilt-table testing

(Class IIa)†

Initial evaluation

suggests CV abnormalities

Cardiac monitor selected based on

frequency and nature (Class I)

Implantable cardiac monitor

(Class IIa)†

Ambulatory external cardiac

monitor (Class IIa)†

Stress testing (Class IIa)†

TTE (Class IIa)†

EPS (Class IIa)†

MRI or CT (Class IIb)†

Initial evaluation unclear

Options

Options

©2018 MFMER | 3743009-11

Neurological Testing: What Not To Do For Syncope Evaluation

Recommendations for Neurological Diagnostics COR LOE Recommendation

III No

Benefit B-NR

MRI and CT of the head are not recommended in the routine evaluation of patients with syncope in the absence of focal neurological findings or head injury that support further evaluation

III No

Benefit B-NR

Carotid artery imaging is not recommended in the routine evaluation of patients with syncope in the absence of focal neurological findings that support further evaluation

III No

Benefit B-NR

Routine recording of an EEG is not recommended in the evaluation of patients with syncope in the absence of specific neurological features suggestive of a seizure

©2018 MFMER | 3743009-12

Electrophysiological Testing After Initial Evaluation

Recommendations for Electrophysiological Study COR LOE Recommendation

IIa B-NR EPS can be useful for evaluation of selected patients with syncope of suspected arrhythmic etiology

III: No Benef

it B-NR

EPS is not recommended for syncope evaluation in patients with a normal ECG and normal cardiac structure and function, unless an arrhythmic etiology is suspected.

©2018 MFMER | 3743009-13

Recommendations for Tilt-Table Testing COR LOE Recommendation

IIa B-R If the diagnosis is unclear after initial evaluation, tilt-table testing can be useful for patients with suspected VVS

III: No Benefit B-R Tilt-table testing is not recommended to predict a

response to medical treatments for VVS

Tilt-Table Testing

©2018 MFMER | 3743009-14

Vasovagal Syncope VVS

Education on diagnosis and prognosis

(Class I)

Counter pressure maneuvers (Class IIa)

Salt and fluid intake

(Class IIb)

Midodrine (Class IIa)

Fludrocortisone (Class IIb)

Beta blocker (in patients ≥42 y)

(Class IIb) Orthostatic training

(Class IIb) Selected serotonin reuptake inhibitors

(Class IIb)

Dual-chamber pacemaker therapy

(Clas IIb)

VVS recurs

Options

Options

©2018 MFMER | 3743009-15

2017 ACC/AHA/HRS Syncope Guidelines Syncope and Driving: “Suggestions”

Shen et al: Circ, 2017

VVS • No syncope in the prior year • 1-6 syncope/year • > 6 syncope/year

• No restrictions • 1 month • Not fit

Bradycardia • Untreated • PPM

• Not fit • 1 week

Presumed supraventricular arrhythmia • Untreated • Pharmacologically suppressed • Ablation

• Not fit • 1 month • 1 week

Presumed ventricular arrhythmia • No ICD, GDMT, or ablation • ICD, GDMT, ablation

• Not fit • 3 months

Unknown etiology • 1 month

©2018 MFMER | 3743009-16

Syncope and Driving: Does It Matter Any More?

©2018 MFMER | 3743009-17

Take Home Message Syncope, effective management • Syncope is a SYMPTOM • Initial evaluation: History!! Exam, ECG • Appropriate testing based on initial evaluation; a broad

range of testing is not recommended • Presence of a cardiac condition warrants further

evaluation and risk stratification • Vasovagal syncope is common, mostly benign and

situational although recurrence and injury can be disruptive and devastating

©2018 MFMER | 3743009-18

Syncope: Effective Management

Cedars, 2019