Syncope AHD[1]
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Transcript of Syncope AHD[1]
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8/8/2019 Syncope AHD[1]
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DefinitionyA transient loss of consciousness accompanied by an
inability to maintain postural tone
y Resolves spontaneouslywithout interventiony Duration seconds - minutes
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Epidemiologyy In the US . . .
y 3% of ED visits
y
6% of admissionsy Costs $750 million annually
y Common in elderlyy CAD
y Polypharmacy
y Neuropathiesy Autonomic instability
y Incidence < 0.1% in children
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Mortality / Morbidityy Mortality at 1 year . . .
y 20-30% if cardiac
y 2-6% if etiology unknowny Major potential for morbidity
y Head injury
y Lacerations
y Extremity fractures
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Is it Syncope?y Dizziness, presyncope, drop attacks and vertigo: No
LOC
SEIZURE SYNCOPE
Duration ofUnconsciousness >5min
Seconds-minutes
Slowreturn to baselinemental status
Oriented immediately after
Bladder Incontinence Bladder Control Retained
Aura Prodromal Sx andcomplaints during episode
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Differential Diagnosesw NeurallyMediated Syncope (24%)
w Vasovagal
w Situational
w Carotid Sinus
w Orthostatic Hypotension (10%)
w Psychiatric Disorders (2%)
w NeurologicDz (10%)
- TIA in Vertebrobasilar circ.w Cardiac Syncope
x Organic Heart Dz (4%)
x Arrhythmias (14%) UNKNOWNUNKNOWN (34(34%)%)
R/O LifeR/O Life--threateningthreateningDxDx: PE, Blood Loss,: PE, Blood Loss,Subarachnoid Hem,Subarachnoid Hem,Some CardiacSome Cardiac
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Pathophysiology 101y Syncopewill result if
y blood flowis less than 20ml/100g/min
y if it stops for 3-5 secondsy Can be due to:
I. regional hypoperfusion- i.e cerebrovascconstriction/dz
II. systemic hypotension- mechanical obstruction,arrythymias, hypovolemia, dysfunctional vasovagal
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Cardiogenic Syncopey 18% of Syncope
y 1 year mortality 30%
y 2 main mechanismsy Arrhythmias
y Mechanical Obstruction- Aortic Stenosis, HypertrophicCardiomyopathy, Pulm HTN
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Arrhythmiasy Most common cardiac cause
y < 10 sec
y Usually suddenwith no prodromey Unrelated to posture or exertion
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Arrhythmiasy Tachyarrhythmias
y V-Tach
y
Torsades de pointsy Rarely SVT
y Long QT syndrome
y Bradyarrhythmiasy Sick sinus
y Blocks
y Pacemaker malfunction
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Mechanical Obstructiony Often exertional
y Right-sided outflowobstruction
y Pulmonary stenosisy PE
y Left-sided outflowobstructiony Aorticstenosis
y
Hypertrophicobstructivecardiomyopathyy Aortic dissection
y Cardiac tamponade
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Orthostatic Syncopey Most common type in elderly
y Brought on by sudden standing or prolonged standing
y Blunted baroreceptor responsewhich results in failureof cardiac compensation following hypotension
- i.e. increased vagal tone
y Decreased vasomotor toney Neuropathies
y Decreased intravascular volumey Hemorrhage, Dehydration, Sepsis, Meds
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Vasovagal Syncopey aka fainting
y MOST COMMON CAUSE OF SYNCOPE in YOUNGP
Tsy emotional/noxious stimuli
y Normal: Standing upblood pools in LE Decrease inCO, SV and BP changes compensated by symptonevasoconstrict & Tachycardia.
y Syncope: Compensatory resp. interrupted byparadoxical withdrawal of symp stimulation andreplacement by parasymp brady, vasodilation,decrease BP and cerebral perfusion
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Vasovagaly Can be prevented/reversed with supine position and
elevation of legs
y Less common in elderly because ofdecreased vagal tone and decreased B-adrenergiccontractility
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Historyy Prodrome
y Events before, during and after episode
y
Posture before episodey Stressors-blood, pain, emotional, fatigue, heat,
prolonged standing, cough/defecation/swallowing
y Duration; rate of recovery
y
Assoc. Sx: CP, palpitations, neuro
y Seizure?
y Trauma?
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PRODROMEy 70% experience a prodrome
y Pallor, diaphoresis
y
Nausea or vomitingy Faintness, dizziness
y Blurring/dimming vision, constriction of visual fields,paralysis of voluntary lateral gaze, EOM fixed
y Yawning, ringing in ears
y Parasthesias
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Medicationsy blockers
y Diuretics
y DigoxinyAntipsychotics
yAntidepressants
y Phenothiazines
yAlcohol
yAntidysrhythmics
yAntiparkinsonism drugs
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Physical ExamyVitals including orthostatics
y -Significant changes includey
Systolic 20 mm Hgy Diastolic 10 mm Hg
y Heart rate 20 bpm
y Fever
yVolume status
y CVS
- Murmurs, Carotid pulses for bruits, pressure tocarotid sinus
y CNS
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Workupy 40-60% nondiagnostic
y Hx + PE should diagnose 50-60% of patients
y *Need to decide if presence/absence of structuralheart dz
y EKG in all patients
y CBC, metabolic panel, not of great utility
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Workup- IfAbn EKGy Cardiac monitor
-HM: if frequent events of arrhythmia
-Event Recorder/Loop: if infrequent events-Implantable Event Recorder: syncope 1-2x/yr
y ECHO- Diagnostic if either severe aortic stenosis or anatrial myxoma is identified
y ETT- w/exertional syncope, r/o ischemia orcathecholamine-induced arrythmias
y Cardiac Catheterization- If previous tests suggestischemia
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Workupy Tilt-Table Test
y Neurologic Studies
-lowyield- EEG, CT, MRI for
Neurologic; lowyield
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TreatmentyArrhythmia, cardiac mechanical, neuro: trx underlyingyVaso-vagal:
y Orthostatic: volume repletion, compressive stockings,midodrine (alpha1-agonist), fludocortisone, high Na
diet (volume expansion). Beta-blockers often used firstline, but studies showno more effective than placebo.
y Patient Education
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Bottom Liney Syncope is a common event
yA symptom, not a diagnosis!!
y Usually benign, but missed events can be catastrophicy Biggest yield from Hx, PE, EKG
y Diagnostic in 50-80% of cases