SYNCOPE: WHAT SYNCOPE: WHAT HAPPENS WHEN YOUR HAPPENS WHEN YOUR

LIGHTS GO OUT LIGHTS GO OUT ??

Syed RazaSyed RazaMD,MRCP (UK),FCCP, Dip.Card (UK)MD,MRCP (UK),FCCP, Dip.Card (UK)

COMMON SCENARIO !COMMON SCENARIO !

Elderly lady Elderly lady Lives aloneLives alone Collapse at home Collapse at home ? LOC? LOC No eye witnessNo eye witness Patient does not remember the eventPatient does not remember the event

Mrs L, 64yo F

66yo F

,

Mrs K, 59yo F

Case Case Mrs M, 85yo F

ObjectivesObjectives

DefinitionDefinition PrevalencePrevalence Diagnostic Work UpDiagnostic Work Up ManagementManagement Implications on drivingImplications on driving

Syncope:Syncope:A Symptom, Not a DiagnosisA Symptom, Not a Diagnosis

Syncope:Syncope:A Symptom, Not a DiagnosisA Symptom, Not a Diagnosis

Self-limited loss of consciousness and Self-limited loss of consciousness and postural tonepostural tone

Relatively rapid onsetRelatively rapid onset Variable warning symptomsVariable warning symptoms Spontaneous, complete, and usually prompt Spontaneous, complete, and usually prompt

recovery without medical or surgical recovery without medical or surgical interventionintervention

Lipsitz 1983Lipsitz 1983

Underlying mechanism: Underlying mechanism: transient global cerebral hypoperfusion.transient global cerebral hypoperfusion.

Impact of SyncopeImpact of Syncope

1Kenny RA, Kapoor WN. In: Benditt D, et al. eds. The Evaluation and Treatment of Syncope. Futura;2003:23-27.2Kapoor W. Medicine. 1990;69:160-175.

3Brignole M, et al. Europace. 2003;5:293-298.4 Blanc J-J, et al. Eur Heart J. 2002;23:815-820.5Campbell A, et al. Age and Ageing. 1981;10:264-270.

40% will experience syncope at least once in a lifetime1

1-6% of hospital admissions2

1% of emergency room visits per year3,4

10% of falls by elderly are due to syncope5

Major morbidity reported in 6%1

eg, fractures, motor vehicle accidents

Minor injury in 29%1

eg, lacerations, bruises

THE COSTTHE COST

More than 1 billion pounds per year spent More than 1 billion pounds per year spent by NHS for managing falls and syncope.by NHS for managing falls and syncope.

Significant portion of the budget is spent Significant portion of the budget is spent onon

clinical conditions which have been clinical conditions which have been misdiagnosed ( i.e. 10% of syncope misdiagnosed ( i.e. 10% of syncope diagnosed as epilepsy)diagnosed as epilepsy)

Incidence Rates of Syncope According to Age and Sex

Soteriades, E. et al. N Engl J Med 2002;347:878-885

ClassificationClassification

Syncope

Neurally Mediated 34%VasovagalCarotid SinusSituationalGlossopharyngeal NeuralgiaCerebrovascularAutonomic Failure

Cardiac Mediated 18%ArrythmiaSrtructural Heart DiseaseCardiopulmonary Disease

Others 47%Orthostatic HypotensionIdiopathicMedicationsPsychiatric

Causes of syncope*

Neurally mediated 50%

Cardiac arrhythmia 11%

Orthostatic hypotension 6%

Structural cardiopulmonary 3%

Unknown 9%

* Data pooled from 4 population studies n=1640 patients

Neurally Mediated Neurally Mediated SyncopeSyncope

Neuro cardiogenic syncope Neuro cardiogenic syncope Carotid sinus hypersensitivityCarotid sinus hypersensitivity Visceral syncope (micturition, Visceral syncope (micturition,

cough, defecation etc.)cough, defecation etc.) Glossopharyngeal neuralgia Glossopharyngeal neuralgia

Neurally Mediated Neurally Mediated SyncopeSyncope

(autonomic failure)(autonomic failure) Orthostatic /Postural HypotensionOrthostatic /Postural Hypotension

Postural Orthostatic Tachycardia Postural Orthostatic Tachycardia Syndrome (POTS)Syndrome (POTS)

Neuro-Cardiogenic Neuro-Cardiogenic SyncopeSyncope

Commonest cause of syncope Commonest cause of syncope Most frequently in 30 - 50 age groupMost frequently in 30 - 50 age group Typical triggers - pain, fear, blood etcTypical triggers - pain, fear, blood etc Prodromal symptoms- warmth, nausea, Prodromal symptoms- warmth, nausea,

sweatingsweating Good history is key to diagnosisGood history is key to diagnosis Usually does not require fancy Usually does not require fancy

investigationsinvestigations Patient may be discharged the same dayPatient may be discharged the same day

PathophysiologyPathophysiology

Neuro-cardiovascular reflexes severely Neuro-cardiovascular reflexes severely impaired or absent.impaired or absent.

Pooling of 500-800 ml blood in distensible Pooling of 500-800 ml blood in distensible blood vessels of legs on prolonged standing.blood vessels of legs on prolonged standing.

Reduced venous return and cardiac output.Reduced venous return and cardiac output. Reduced brain perfusion.Reduced brain perfusion. Warning signals to brain impairedWarning signals to brain impaired Patient presents with pre syncope or Patient presents with pre syncope or

syncopesyncope

Carotid Sinus SyndromeCarotid Sinus Syndrome

Common in elderly/atherosclerotic ds.Common in elderly/atherosclerotic ds. Sensitive baro receptors at carotid bodySensitive baro receptors at carotid body Any pressure i.e. sudden neck turningAny pressure i.e. sudden neck turning

or tight collar /shavingor tight collar /shaving slowing of heart rate and fall in blood slowing of heart rate and fall in blood

pressurepressure Poor brain perfusion → SyncopePoor brain perfusion → Syncope

Carotid Sinus Syncope and Autonomic Dysfunction

Freeman, M. Neurogenic Orthostatic Hypotension. NEJM 2008; 358: 616

POSTURAL BPPOSTURAL BP

Postural Blood PressurePostural Blood Pressure

Sadly NOT accurately measuredSadly NOT accurately measured Supine position –at least 10 minutesSupine position –at least 10 minutes Standing/SittingStanding/Sitting Measure BP immediately, 1 minute , 3 Measure BP immediately, 1 minute , 3

minutesminutes

Symptoms of pre-syncope or syncopeSymptoms of pre-syncope or syncope Fall in systolic BP by 30 mmHg AND Fall in systolic BP by 30 mmHg AND

diastolic BP by 20 mmHgdiastolic BP by 20 mmHg..

Orthostatic HypotensionOrthostatic Hypotension

Common in elderlyCommon in elderly

most vulnerablemost vulnerable ↓ ↓ Baro receptor sensitivityBaro receptor sensitivity Reduced thirst mechanismReduced thirst mechanism Poly pharmacyPoly pharmacy

Peripheral sympathetic tone Peripheral sympathetic tone impairmentimpairment

Diabetic neuropathy, antihypertensive Diabetic neuropathy, antihypertensive medicationmedication

POSTURAL ORTHOSTATIC POSTURAL ORTHOSTATIC TACHYCARDIA SYNDROME TACHYCARDIA SYNDROME

(POTS)(POTS)Patients ( women 15-50)Patients ( women 15-50)

dizziness or faint on acquiring sudden erect dizziness or faint on acquiring sudden erect postureposture

Reduced volume of blood reaches the heartReduced volume of blood reaches the heart Stimulation of mechano receptors causes Stimulation of mechano receptors causes

tachycardiatachycardia Heart rate increases by more than 30 Heart rate increases by more than 30

beats/min.beats/min. Heart rate usually above 120 /minute.Heart rate usually above 120 /minute.

Initial evaluation: HistoryInitial evaluation: History

Prior to eventPrior to event

Position, activity, situation (urinating etc)Position, activity, situation (urinating etc)

predisposing factors (crowded, warm place etc)predisposing factors (crowded, warm place etc)

precipitating events (fear, pain, neck movements)precipitating events (fear, pain, neck movements)

Onset of eventOnset of event

nausea, vomiting, sweating, aura, nausea, vomiting, sweating, aura,

About event (eye witness)About event (eye witness)

Colour, duration, movements, tongue bitingColour, duration, movements, tongue biting

After the eventAfter the eventnausea, vomiting, sweating, confusion, muscle ache, skin nausea, vomiting, sweating, confusion, muscle ache, skin colour, woundscolour, wounds

Diagnostic testsDiagnostic tests

Carotid sinus massageCarotid sinus massage

Tilt testingTilt testing

Others; EP testing, signal averaged (V) Others; EP testing, signal averaged (V) ECG, Echocardiography, ETT, cardiac ECG, Echocardiography, ETT, cardiac catheterisation, neurological/psychiatric catheterisation, neurological/psychiatric evaluation,evaluation,

Carotid Sinus Massage Carotid Sinus Massage ProtocolProtocol

Massage longitudinally, site of maximal impulse, Massage longitudinally, site of maximal impulse, anterior margin SCM muscle level of cricoid anterior margin SCM muscle level of cricoid cartilagecartilage

5 –10 seconds, right first, then left after 1-2 5 –10 seconds, right first, then left after 1-2 minute break (minute break (Newcastle protocol 10secsNewcastle protocol 10secs))

Continuous ECG and BP monitoring mandatoryContinuous ECG and BP monitoring mandatory

Neurological complication in 0.45% in a series of Neurological complication in 0.45% in a series of 1600 patients (5secs massage)1600 patients (5secs massage)

Carotid Sinus MassageCarotid Sinus Massage

Stimulation of hypersensitive carotid body can produce 3 main responses

Cardio-inhibitory response (70%)

Vasodepressor response (10%)

Mixed (20%)

Positive CSM TestPositive CSM Test

Significant brady /more than 3 s Significant brady /more than 3 s pause on the ECG pause on the ECG

More than 50 mmHg fall in systolic More than 50 mmHg fall in systolic BP BP

Mixed response Mixed response

TILT TABLE TESTTILT TABLE TEST

Tilt Table Test In ActionTilt Table Test In Action

Indications for Tilt Table Indications for Tilt Table TestingTesting

Unexplained recurrent syncopeUnexplained recurrent syncope

Assessment of recurrent, unexplained Assessment of recurrent, unexplained fallfall

Syncope with suspected autonomic Syncope with suspected autonomic failurefailure

After a cardiac cause for syncope has After a cardiac cause for syncope has been excludedbeen excluded

Upright Tilt Table TestUpright Tilt Table Test

Measure HR and Measure HR and BP while tilting BP while tilting them uprightthem upright

Attempt to elicit Attempt to elicit symptomssymptoms

Tilt Table TestingTilt Table Testing

Supine at least 20 minutes prior to tiltSupine at least 20 minutes prior to tilt Tilt angle 70 degreesTilt angle 70 degrees Passive phase min 20 to 45 minutesPassive phase min 20 to 45 minutes Use either intravenous isoprenaline or Use either intravenous isoprenaline or

sublingual GTN if passive phase is sublingual GTN if passive phase is negativenegative

Pharmacological phase – 15 to 20 minutesPharmacological phase – 15 to 20 minutes End-point: induction syncope End-point: induction syncope

Normal test

Cardioinhibitory response Cardioinhibitory response

Vasodepressor responseVasodepressor responseBP drops from 150/70 to 50/30 but BP drops from 150/70 to 50/30 but

heart rate stays sameheart rate stays same

Mixed responseMixed responseBP drops from 150/60 to 50/20 BP drops from 150/60 to 50/20

while HR drops from 65 to 30bpmwhile HR drops from 65 to 30bpm

Orthostatic hypotensionOrthostatic hypotensionsteady drop in BP and rise in HRsteady drop in BP and rise in HR

Heart Monitoring OptionsHeart Monitoring OptionsSyncope Occurs Infrequently, Syncope Occurs Infrequently,

Long-term Monitoring is Likely to be Most Long-term Monitoring is Likely to be Most EffectiveEffective

Heart Monitoring OptionsHeart Monitoring OptionsSyncope Occurs Infrequently, Syncope Occurs Infrequently,

Long-term Monitoring is Likely to be Most Long-term Monitoring is Likely to be Most EffectiveEffective

ILRILR

MCOT MCOT ExternalExternal

Loop Loop RecorderRecorder

Typical EventTypical EventRecorderRecorder

Holter Holter MonitorMonitor

12-Lead12-Lead

2 Days2 Days

7 Days7 Days

30+ Days30+ Days

36 Months36 Months

10 Seconds10 Seconds

ILR = insertable loop recorderILR = insertable loop recorder

MCOT= mobile cardiac outpatient telemetryMCOT= mobile cardiac outpatient telemetry

Everything is spinningEverything is spinning

MANAGEMENTMANAGEMENT

Patient education and counsellingPatient education and counselling Avoid triggersAvoid triggers Increase in salt and fluid intakeIncrease in salt and fluid intake Sleeping with the head of the bed Sleeping with the head of the bed

raised (6-12 inches.raised (6-12 inches. Elastic stockingsElastic stockings Preventing LOC or InjuryPreventing LOC or Injury

Assume supine position upon onset of prodromeAssume supine position upon onset of prodrome Avoid driving or other activities that could lead Avoid driving or other activities that could lead

to injuryto injury

Pharmacological therapyPharmacological therapy

Beta blockersBeta blockers DysopyramideDysopyramide FludrocortisoneFludrocortisone SSRIsSSRIs MidodrineMidodrine

Management of Neurally Management of Neurally Mediated SyncopeMediated Syncope

Grubb BP. NEJM. 2005. 352(10): 1004-1010

INDICATION FOR INDICATION FOR PACEMAKER PACEMAKER

Syncope with cardio inhibitory or Syncope with cardio inhibitory or

mixed (cardio-inhibitory plus mixed (cardio-inhibitory plus vasodepressor).vasodepressor).

Severe brady cardia, AV or SA Severe brady cardia, AV or SA blockblock

Over drive pacing for some tachy Over drive pacing for some tachy arrhythmia.arrhythmia.

• Non-random, observational

• RCTs comparing vs

• RCTs comparing vs

What are the indications for What are the indications for pacemaker therapy in pacemaker therapy in

neurocardiogenic syncope?neurocardiogenic syncope?

2727 dual-chamber dual-chamber pacemakerspacemakers

with rate-drop with rate-drop responseresponse

54 pts54 pts2727 No pacemaker No pacemaker

Included• >6 lifetime episodes• + tilt-table test

– (relative bradycardia)

Primary outcome: first recurrence of syncope

Pacemaker No pacemaker

Recurrence of Syncope

6/27 (22%) 19/27 (70%)

Time to recurrence

112 days 54 days

Excluded• Vascular, coronary,

myocardial or conduction system disease

The North American The North American Vasovagal Pacemaker Study Vasovagal Pacemaker Study

(VPS)(VPS)

J. Am. Coll Cardiol. 1999;33:16-20

Soteriades E et al. N Engl J Med 2002;347:878-885

Overall Survival of Participants with Syncope, According to Cause, and Participants without Syncope

Driving ImplicationsDriving ImplicationsGroup 1 EntitlementGroup 1 Entitlement Group 2 EntitlementGroup 2 Entitlement

Simple faint –definite Simple faint –definite provocation with provocation with prodromal symptomsprodromal symptoms

No driving restrictionsNo driving restrictions No driving restrictionsNo driving restrictions

Unexplained syncope Unexplained syncope with low risk of with low risk of recurrencerecurrence

Can drive 4 weeks after Can drive 4 weeks after the eventthe event

Can drive 3 months Can drive 3 months after the eventafter the event

Unexplained syncope Unexplained syncope & high risk of & high risk of recurrencerecurrence

A abnormal ECGA abnormal ECG

B structural heart B structural heart diseasedisease

C syncope at the C syncope at the wheel or results in wheel or results in injuryinjury

D more than 1 D more than 1 episode in last 6 episode in last 6 monthsmonths

Can drive 4 weeks after Can drive 4 weeks after the event if cause the event if cause identified and treatedidentified and treated

If no cause – 6 months If no cause – 6 months offoff

Can drive after 3 Can drive after 3 months if the cause months if the cause identified and treatedidentified and treated

If no cause, licence If no cause, licence revoked for yearrevoked for year

Loss of Loss of consciousness with consciousness with no clinical pointersno clinical pointers

Full neuro/cardiac Ix Full neuro/cardiac Ix with no pointerswith no pointers

Licence revoked for 6 Licence revoked for 6 monthsmonths

Licence revoked for 1 Licence revoked for 1 yearyear

Cough syncopeCough syncope Stop driving until Stop driving until symptoms controlledsymptoms controlled

Stop drivingStop driving

If smokes or If smokes or respiratory disease respiratory disease have to be controlled have to be controlled for 5 yearsfor 5 years

SUMMARYSUMMARY

Syncope is not an uncommon problemSyncope is not an uncommon problem The diagnosis of syncope is often The diagnosis of syncope is often

missed or it is misdiagnosedmissed or it is misdiagnosed Thorough history from eye witness can Thorough history from eye witness can

be very helpfulbe very helpful Syncope can be fatalSyncope can be fatal Further training to identify the Further training to identify the

problem and formulating a plan of problem and formulating a plan of management is needed.management is needed.

ANY QUESTION ??ANY QUESTION ??