SYNCOPE 2007: Some Principles and Some Cases Mark Linzer, M.D. General Internal Medicine UW-Madison.

SYNCOPE 2007:Some Principles and Some Cases

Mark Linzer, M.D.

General Internal Medicine

UW-Madison

Financial Disclosure

• No external support for this talk

• Prior grant support: – Instromedix, Inc. (loop ECG recorders)– Mellon Foundation (EP studies) – Dutch Heart Assn. (QOL)

• Recent talk at International Syncope Symposium supported by Blackwell Publishing Company

Objectives

• Know the diagnostic categories

• Recognize the value of history taking

• Learn to choose among diagnostic tests

• Know that cardiac syncope carries high risk; when to think of AICDs, pacemakers

• Be adept at listening to a syncope case and knowing what to do!

Diagnostic categories

• Vasovagal (neurocardiogenic); including situational

• Orthostatic hypotension

• Meds, Psychiatric

• Neurologic

• Cardiac (VHD, PE, MI, arrhythmia)

• SUO

History is everything (or just about)*

• Sudden syncope

• Warmth, nausea, diaphoresis

• Positional

• Anxiety, mood disturbance, multiple sx

• Seizure activity, neuro sx

• Exertion, chest pn, palpitations, injury• SOB *Linzer M. Ann Intern Med 1997; 126;989-96; 127;76-86. and Van

Dijk N, Wieling W. Dutch FAST trial: watch for pubs!

In the presence of heart disease…

• Take a full history• Examine• Check ECG (incl. QT) • Test aggressively • Admit• If CHF, think AICD (Knight B. JACC. 1999;33:1964-70)

• If BBB or SND with normal LV, think pacemaker

Diagnostics

• Labs: not much value (acidosis, sz)

• ECG: in just about everyone; CSM?

• Neuro tests: only if signs or sx• Echo: assess substrate(Sarasin F. Heart. 2002;88:363-7);

IHSS, CoCM, CAD, AS: refer.

• Stress test: exertional sx; ? in elderly (echo first)

• Holter: background arrhythmias

More tests

• EP studies: OHD, BBB.

• Loop ECG recording: infrequent LOC or palpitations without OHD– Ambulatory loop (Linzer M, AJC. 1990;66:214-19)

– Implantable Loop (ILR) (Krahn A. JACC 2003;42:495-501)

• Tilt test: r/o vasovagal/reflex syncope

• Psychiatric evaluation

When to admit*

• OHD

• ECG abnormalities (e.g. CAD, long QT, SND, BBB)

• Exertional sx; palpitations; injury; chest pn; dyspnea

• FH sudden death• Severe OH (*From European Task Force on Syncope.

Europace. 2004;6:467-537).

Quality of Life, driving issues

• Syncope has serious impact on QOL (Van Dijk N.

J Cardiovasc Electrophys. 2006;17:998-1003)

• Driving should often be restricted (European Task Force. Europace. 2004;6:467-537)

– Private vs. vocational drivers– Duration of restriction related to etiology and

when sx occurred– Often 3-12 months

Case 1*

• Case 1 (#22): A 23 yo man with GERD and syncope while swallowing

*From Garcia-Civera R. Syncope Cases. Blackwell Futura. Malden, MA. 2006.

Giada F, Raviele A. Swallow syncope associated with asystole. In: Syncope Cases. Garcia-Civera R, Baron- Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 62.

Case 1

Case 2*

• Case 2 (#28): A 23 year old woman with recurrent vasovagal-like episodes. How to diagnose?

*From Garcia-Civera R. Syncope Cases. Blackwell Futura.

Malden, MA. 2006.

Romero N, Baron Esquivias G, Gomez Moreno S, et al. Long-term follow-up of vasovagal syncope with a long asystolic pause. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 79.

Case 2

Case 3*

• Case 3 (#29): A 28 yo man with recurrent vasovagal episodes. How to treat?

*From Garcia-Civera R. Syncope Cases. Blackwell Futura. Malden, MA.

2006.

Krediet CTP, van Dijk N, Wieling W. Averting a vasovagal faint with a combination of leg crossing and muscle tensing. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 82.

Case 3

Case 4*

• Case 4 (#42): A 20 yo man with lightheadedness and syncope shortly

(5-10 sec) after standing.


2006.

van Dijk N, Harms MPM, Wieling W. Initial orthostatic hypotension as a cause of syncope in an adolescent. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 118

Case 4

Case 5*

• Case 5 (#52): A 73 yo man with HBP and multiple positional (orthostatic) episodes of syncope


Daga Calejero B, Gutierrez Ibanez E, Carmona Ainat A, Sanchez Val A, et al. Orthostatic hypotension and syncope in a patient with pheochromocytoma. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 148.

Case 5

Case 6*

• Case 6 (#53): A 28 yo man with unprovoked syncope and a borderline ECG.


2006.

Garcia Civera R, Ruiz Granell R, Morell Cabedo S, Sanjuan Manez R. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 153.

Case 6

Garcia Civera R, Ruiz Granell R, Morell Cabedo S, Sanjuan Manez R. In: Syncope Cases. Garcia-Civera R,Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 154.

Case 6

Case 7*

• Case 7 (#59): A 16 yo boy who collapsed during a soccer match 6 years ago; his brother recently died suddenly.


2006.

Wilde AAM, Simmers TA. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 170.

Case 7

Wilde AAM, Simmers TA. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 171.

Case 7

Case 8*

• Case 8 (#86): a 48 yo smoker with discomfort and dizziness while driving, and syncope after exiting the car (who then drove to the hospital).


2006.

Sanchez Gonzalez A, Fournier Andray JA, Ballesteros Pradas SM, Diaz de la Llera LS, Villa Gil-Ortega M. Syncope as an isolated manifestation of left main coronary artery occlusion. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 247.

Case 8

Case 9*

• Case 9 (#91): A 45 yo man with two syncopal spells, LBBB, EF 30%, neg cath, NSVT on Holter, and neg EPS.


2006.

Case 10*

• Case 10 (#99): A 50 yo man with a 3/6 SEM and syncope while walking to work.


Tornos P. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 286.

Case 10

Tornos P. Syncope in aortic stenosis. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 287.

Case 10

Case 11*

• Case 11 (#105): a 68 yo woman with HBP, chest and back pain, then syncope.


2006.

Sanjuan Manez R, Blasco ML, Martinez Leon J, Ruiz Granell R. Syncope in acute aortic dissection. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 305.

Case 11

Case 12*

• Case 12 (#106): an 86 yo woman with breast Ca, hx of PE, and two episodes of syncope.


2006.

Montagud Balaguer V, Pelaez Gonzalez A, Aguar Carrascosa P, Tuzon Segarra MT, Salvador Sanz A. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 308.

Case 12

Montagud Balaguer V, Pelaez Gonzalez A, Aguar Carrascosa P, Tuzon Segarra MT, Salvador Sanz A. Pulmonary embolism presenting as syncope. In: Syncope Cases. Garcia-Civera R, Baron-Esquivias G, Blanc JJ, Brignole M, et al. (eds), Blackwell Futura, Malden, MA. (2006) p. 308.

Case 12

In summary:

• Syncope can be diagnosed.

• Syncope can be treated.

• Heart disease means serious syncope.

• The history, physical exam and ECG mean a lot!

SYNCOPE 2007: Some Principles and Some Cases Mark Linzer, M.D. General Internal Medicine UW-Madison.

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