SyncopeSyncope

Courtney McIlduff, M. Sc.Courtney McIlduff, M. Sc.

Catherine Florio Pipas, M. D.Catherine Florio Pipas, M. D.

Dartmouth Medical SchoolDartmouth Medical School

ObjectivesObjectives Present a Clinical CasePresent a Clinical Case

Define SyncopeDefine Syncope

Provide an Overview of Syncope StatisticsProvide an Overview of Syncope Statistics

Explore the Differential Diagnosis of SyncopeExplore the Differential Diagnosis of Syncope

Review a Study to: Review a Study to: Establish a framework for approaching the case Establish a framework for approaching the case Address the question “Why is it so important to distinguish non-Address the question “Why is it so important to distinguish non-

cardiac from cardiac causes of syncope?”cardiac from cardiac causes of syncope?”

Predict Prognosis using an AFP Point of Care GuidePredict Prognosis using an AFP Point of Care Guide

Give a Pop QuizGive a Pop Quiz

Summarize Key PointsSummarize Key Points

Case PresentationCase Presentation

““Jackie” is a 54 year-old woman with Jackie” is a 54 year-old woman with Down SyndromeDown Syndrome

And a history of And a history of seizure disorder seizure disorder

Who presents with her caregiver.Who presents with her caregiver.

Her chief concern is: Her chief concern is: “I keep “I keep fainting.”fainting.”

Case Presentation: HPICase Presentation: HPI3 episodes of syncope over the previous 8 3 episodes of syncope over the previous 8

monthsmonths

- Jackie gets up at 4 am to go to the bathroomJackie gets up at 4 am to go to the bathroom

- Caregiver hears her fall to the floorCaregiver hears her fall to the floor

- Caregiver finds Jackie on her back and Caregiver finds Jackie on her back and “unconscious”“unconscious”

- Jackie remains unarousable for about 5 minutesJackie remains unarousable for about 5 minutes

- Jackie returns to bed Jackie returns to bed

Case Presentation: HPICase Presentation: HPI

No overt seizure activityNo overt seizure activity No injuries No injuries No painNo pain No shortness of breathNo shortness of breath No h/o preceding balance troubleNo h/o preceding balance trouble No h/o light-headednessNo h/o light-headedness No h/o recent illnessNo h/o recent illness History of History of low blood pressurelow blood pressure (home (home

measurements: 90s/60-70s)measurements: 90s/60-70s)

Taking all Taking all medicationsmedications as prescribed as prescribed

Case Presentation: Case Presentation: MedicationsMedications ExelonExelon NeurontinNeurontin TegretolTegretol SeroquelSeroquel LevoxylLevoxyl RanitidineRanitidine

Allergies: No known drug allergiesAllergies: No known drug allergies

Case Presentation: PMHCase Presentation: PMH

Seizure Disorder Seizure Disorder (“Epilepsy with occasional tendency for tonic-clonic Seizures”)(“Epilepsy with occasional tendency for tonic-clonic Seizures”)

Conduct Disorder Conduct Disorder (aggressive outbursts)(aggressive outbursts)

HypothyroidismHypothyroidism

GERDGERD

Case PresentationCase Presentation

Family History:Family History: Significant for breast cancer Significant for breast cancer

(mother)(mother)

Social History:Social History: Lives with her caregiverLives with her caregiver Participates in a Day ProgramParticipates in a Day Program Enjoys X-boxEnjoys X-box

Physical ExamPhysical Exam

Vitals: AfebrileVitals: Afebrile BP: 90/58BP: 90/58 HR: 60HR: 60

Gen: Gen: well-appearing, slightly sleepy woman who well-appearing, slightly sleepy woman who engages well throughout visit with eye contact and engages well throughout visit with eye contact and conversationconversation

CVS: CVS: regular rate and rhythm. Grade II/VI Systolic regular rate and rhythm. Grade II/VI Systolic ejection murmur heard best in aortic regionejection murmur heard best in aortic region

Pulm: Pulm: Clear to auscultation bilaterallyClear to auscultation bilaterally

Initial ImpressionInitial Impression

Recurrent syncopeRecurrent syncope

Definition of SyncopeDefinition of Syncope

Sudden, transient loss of consciousness Sudden, transient loss of consciousness due to cerebral hypoperfusiondue to cerebral hypoperfusion

Associated with loss of postural toneAssociated with loss of postural tone

Usually followed by rapid and complete Usually followed by rapid and complete recoveryrecovery

Syncope StatsSyncope Stats

Common clinical problem: Common clinical problem: 1/3 of people will experience an episode 1/3 of people will experience an episode

of syncope in their lifetimeof syncope in their lifetime

Incidence increases with age, with Incidence increases with age, with sharp rise at 70 yearssharp rise at 70 years

Male = female incidence, BUT men Male = female incidence, BUT men more likely to have cardiac causemore likely to have cardiac cause

Syncope Stats Syncope Stats continuedcontinued

Predictors of Cardiac Causes of Syncope Predictors of Cardiac Causes of Syncope include:include:

Cardiovascular Disease – strongest Cardiovascular Disease – strongest predictor of cardiac causepredictor of cardiac cause

History of Stroke or TIAHistory of Stroke or TIA

HypertensionHypertension

Differential Diagnosis of Differential Diagnosis of Syncope:Syncope:

Non-Cardiac vs CardiacNon-Cardiac vs CardiacNonNon-Cardiac:-Cardiac: NNeurocardiogeniceurocardiogenic OOrthostatic rthostatic

HypotensionHypotension NNeurologiceurologic

SzSz TIATIA

Other: Other: Metabolic: Metabolic:

hypoglycemia, hypoglycemia, hypoxia, anemiahypoxia, anemia

PsychogenicPsychogenic Drug-InducedDrug-Induced

Cardiac:Cardiac: StructuralStructural ArrhythmiaArrhythmia

Category 1: Structural Causes of Category 1: Structural Causes of Cardiac SyncopeCardiac Syncope

Endo: Aortic Stenosis, Mitral Stenosis, Endo: Aortic Stenosis, Mitral Stenosis, Pulm. StenosisPulm. Stenosis

Myo: Myocardial Infarction, Hypertrophic Myo: Myocardial Infarction, Hypertrophic Obstructive CardiomyopathyObstructive Cardiomyopathy

Peri: TamponadePeri: Tamponade

Vasc: Aortic Dissection, PEVasc: Aortic Dissection, PE

Category 2Category 2: : Arrhythmia as a Cause of Cardiac Arrhythmia as a Cause of Cardiac SyncopeSyncope

Tachy:Tachy:

1. Ventricular Tachycardia1. Ventricular Tachycardia

2. Supraventricular Tachycardia2. Supraventricular Tachycardia

Diagnosed by ECGDiagnosed by ECG

Category 2:Category 2: Arrhythmia as a Cause of Arrhythmia as a Cause of Cardiac SyncopeCardiac Syncope

BradyBrady

22ndnd or 3 or 3rdrd Degree AV Block Degree AV Block Conduction of impulse from atria to ventricles is Conduction of impulse from atria to ventricles is

delayeddelayed Atrial impulse fails to reach ventriclesAtrial impulse fails to reach ventricles

Due to Due to Organic heart diseaseOrganic heart disease MedicationMedication

Diagnosed by ECG or Holter MonitorDiagnosed by ECG or Holter Monitor

Category 2: Category 2: Arrhythmia as a Cause of Arrhythmia as a Cause of Cardiac SyncopeCardiac Syncope Bradyarrhythmias continuedBradyarrhythmias continued

Sick Sinus Syndrome (SSS)Sick Sinus Syndrome (SSS)

Delayed or failed conduction between sinus node Delayed or failed conduction between sinus node and atriaand atria

Due to Due to Inadequate sinus node pacingInadequate sinus node pacing Intrinsic / extrinsic (eg meds) conduction Intrinsic / extrinsic (eg meds) conduction

disturbancesdisturbances

Diagnosed by ECG or Holter MonitorDiagnosed by ECG or Holter Monitor Sinus pauseSinus pause (>3 s strongly suggestive of SSS(>3 s strongly suggestive of SSS))

QuestionsQuestions

How can we put the differential How can we put the differential diagnosis into context?diagnosis into context?

Why is it so important to distinguish Why is it so important to distinguish non-cardiac from cardiac causes of non-cardiac from cardiac causes of syncope?syncope?

Study: Context for Study: Context for Approaching Jackie’s CaseApproaching Jackie’s Case

““Incidence and Prognosis of Syncope”Incidence and Prognosis of Syncope”Soteriades E et al. N Engl J Med 2002;347:878-885

Purpose: Purpose: To evaluate incidence, etiology, and To evaluate incidence, etiology, and

prognosis of syncope in Framingham prognosis of syncope in Framingham Heart Study participants from 1971 Heart Study participants from 1971 to 1998. to 1998.

Study Results: Study Results: Over an average follow-up period of 17 Over an average follow-up period of 17

years, 822 of 7814 male and female years, 822 of 7814 male and female participants reported an initial episode of participants reported an initial episode of syncopesyncope

Incidence of syncope: 6.2 per 1000 person-Incidence of syncope: 6.2 per 1000 person-yearsyears

Etiologies most frequently identified:Etiologies most frequently identified: neurocardiogenic (vasovagal)neurocardiogenic (vasovagal) 21.2 %21.2 % cardiac cardiac 9.5 %9.5 % orthostatic orthostatic 9.4 % 9.4 % unknownunknown 36.6 % 36.6 %

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

Study ConclusionsStudy Conclusions Neurocardiogenic (vasovagal) syncope:

Benign No increased risk of death

Syncope of unknown and neurologic causes: Intermediate increase in risk of death from any

cause

Cardiac syncope: Increased risk of death by a factor of 2 Increased risk of cardiovascular events

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

First Distinction: First Distinction: Non-cardiac vs CardiacNon-cardiac vs Cardiac

Non-cardiac causes Non-cardiac causes

most often benignmost often benign self-limitedself-limited

CardiacCardiac

high incidence of high incidence of subsequent cardiac subsequent cardiac arrest (~24%)arrest (~24%)

higher mortality higher mortality rate rate

Jackie: Jackie: evidence for non-cardiac causes evidence for non-cardiac causes of syncopeof syncope

Non-Cardiac:Non-Cardiac: → → NNeurocardiogenic eurocardiogenic

MicturitionMicturition

→ → OOrthostatic Hypotensionrthostatic Hypotension Documented h/o hypotensionDocumented h/o hypotension Timing of incident: rising from bed to go to Timing of incident: rising from bed to go to

bathroombathroom

→ → NNeurologiceurologic Documented Seizure disorderDocumented Seizure disorder

But: But: evidence for cardiac cause of syncopeevidence for cardiac cause of syncope

No Seizure Activity No Seizure Activity

No reported prodrome No reported prodrome (nausea, diaphoresis)(nausea, diaphoresis)

No triggers No triggers (prolonged standing, heat, pain, fear, (prolonged standing, heat, pain, fear, exercise)exercise)

No Recent Medication ChangesNo Recent Medication Changes

Multiple episodes over short period Multiple episodes over short period serious underlying conditionserious underlying condition

Down SyndromeDown Syndrome – – associated with cardiac associated with cardiac abnormalitiesabnormalities

Jackie: Diagnostic Jackie: Diagnostic StudiesStudies Labs:Labs:

CBCCBC Complete Metabolic PanelComplete Metabolic Panel TSHTSH Tegretol LevelTegretol Level all within normal limitsall within normal limits

ECGECG: sinus bradycardia: sinus bradycardia American College of Emergency Physicians recommends ECG if American College of Emergency Physicians recommends ECG if

Hx and PE do not provide dxHx and PE do not provide dx

Jackie: Further Diagnostic Jackie: Further Diagnostic StudiesStudies 24 hour Holter Monitor – performed 24 hour Holter Monitor – performed

due to suspected Sick Sinus due to suspected Sick Sinus SyndromeSyndrome

Results:Results: Avg HR: 55 (min = 36, max = 98)Avg HR: 55 (min = 36, max = 98) Sinus RhythmSinus Rhythm 395 pauses395 pauses

Longest 2.7 secondsLongest 2.7 seconds

  

                                     

        

Jackie: UpdateJackie: Update

Visit with the CardiologistVisit with the Cardiologist

Choices for Future Follow-upChoices for Future Follow-up Event MonitorEvent Monitor Implantable Loop RecorderImplantable Loop Recorder Permanent Pacemaker….Permanent Pacemaker….

Jackie: Predicting Jackie: Predicting MortalityMortality

Jackie, her caregiver, and her family Jackie, her caregiver, and her family decide which follow-up measure to decide which follow-up measure to pursue.pursue.

In the interim, is there a way to In the interim, is there a way to predict her one year mortality rate?predict her one year mortality rate?

“First Syncope Rule”Clinical Risk Score for Predicting One-Year Mortality

in Patients with Syncope

Risk factors

Abnormal electrocardiogram*

Age older than 45 years

History of congestive heart failure

History of ventricular arrhythmia

Number of risk factors One-year mortality rate (%)

0 1

1 9

2 16

3 or 4 27*-Abnormal electrocardiogram does not include sinus bradycardia or tachycardia or nonspecific ST- or T-wave changes alone.

Ebell, Mark H. Syncope: initial evaluation and prognosis. Ebell, Mark H. Syncope: initial evaluation and prognosis. American Family PhysicianAmerican Family Physician 2006; 74(8): 1367-70.2006; 74(8): 1367-70.

What is Jackie’s What is Jackie’s Prognosis?Prognosis?

Abnormal ECG*Abnormal ECG* Age older than 45 Age older than 45

yearsyears h/o congestive h/o congestive

heart failureheart failure h/o ventricular h/o ventricular

arrhythmiaarrhythmia

No No 00Yes Yes 11No No 00

No No 00__________________________________________TotalTotal 1 risk 1 risk

factorfactor

= 1% 1-year mortality = 1% 1-year mortality raterate

Pop QuizPop Quiz

What are the 3 main categories of What are the 3 main categories of Non-Cardiac Causes of Syncope?Non-Cardiac Causes of Syncope?

Hint: N-O-N cardiac….Hint: N-O-N cardiac….

Pop QuizPop Quiz

What are the 2 main categories of What are the 2 main categories of Cardiac Causes of Syncope?Cardiac Causes of Syncope?

SummarySummaryNon-Cardiac:Non-Cardiac: NNeurocardiogenic (vaso-eurocardiogenic (vaso-

vagal: Reflex Mech.s)vagal: Reflex Mech.s) OOrthostatic Hypotensionrthostatic Hypotension NNeurologiceurologic

SzSz TIATIA

Other: Other: Metabolic: hypoglycemia, Metabolic: hypoglycemia,

hypoxia, anemiahypoxia, anemia PsychogenicPsychogenic Drug-InducedDrug-Induced

Cardiac:Cardiac: ArrhythmiaArrhythmia

TachyTachy VTVT SVTSVT

BradyBrady AV BlockAV Block Sick SinusSick Sinus

StructuralStructural Endo: AS, MS, PSEndo: AS, MS, PS Myo: MI, HOCMMyo: MI, HOCM Peri: tamponadePeri: tamponade Vasc: aortic dissection, Vasc: aortic dissection,

PEPE

Questions?Questions?

Thank you!Thank you!

References & ResourcesReferences & Resources CIS RecordsCIS Records

CP Online: http://cponline.hitchcock.org/CP Online: http://cponline.hitchcock.org/

Ebell, Mark H. Syncope: initial evaluation and prognosis. Ebell, Mark H. Syncope: initial evaluation and prognosis. American Family PhysicianAmerican Family Physician 2006; 74(8): 1367-70. 2006; 74(8): 1367-70.

Elpidoforos, Soteriades, S., Evans, Jane C., Larson, Martin Elpidoforos, Soteriades, S., Evans, Jane C., Larson, Martin G., Chen, Ming Hui, Chen, Leway, Benjamin, Emelia J., and G., Chen, Ming Hui, Chen, Leway, Benjamin, Emelia J., and Levy, Daniel.Levy, Daniel. Incidence and prognosis of syncope. Incidence and prognosis of syncope. New New England Journal of MedicineEngland Journal of Medicine 2002; 347:878-885. 2002; 347:878-885.

Olshansky, B (2006).Pathogenesis and etiology of syncope. Olshansky, B (2006).Pathogenesis and etiology of syncope. Retrieved January, 2007 from Retrieved January, 2007 from http://www.uptodateonline.comhttp://www.uptodateonline.com

Sabatine, M. S. (2004). Sabatine, M. S. (2004). Pocket Medicine: The Massachusetts Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine General Hospital Handbook of Internal Medicine New York: New York: Lippincott Williams & Wilkins.Lippincott Williams & Wilkins.