Syncope and The Older Patient

Debra L. Bynum, MD

Division of Geriatric Medicine

Pretest… 1. The ECG has the greatest value in its (NPV or PPV) in the diagnosis of a

cardiac etiology for syncope 2. History: 75 year old man reports presyncopal symptoms that occur while he

is driving backwards out of his driveway in the morning. This suggests … 3. History: an 80 year old man reports an episode of syncope that occurred

after doing arm exercises for a rotator cuff injury. This suggest… 4. The only independent predictor of a cardiac etiology of syncope is a past

history of … 5. ____ is a neurodegenerative disease characterized by profound autonomic

insufficiency and parkinsonian features on exam 6. An 82 year old man presents with postural hypotension, an idiopathic

peripheral neuropathy, significant proteinuria and your attending orders a rectal biopsy to look for____

7. Name 3 causes of “situational syncope” 8. Older patients are more likely to have positive a. tilt table tests b. carotid

sinus massage c. orthostatic hypotension d. all of the above

Pretest: bonus question

Sudden cardiac death in young men (originally described in young asian men) associated with this sign on EKG is known as what syndrome?

Outline

What is syncope What are the causes of syncope How do you evaluate the patient with

syncope? How do you risk stratify the patient with

syncope? How do you treat?

Syncope: Definition

Transient Loss of Consciousness (T-LOC) due to global cerebral hypoperfusion Rapid onset, short duration, complete recovery

Other causes of T-LOC that are NOT syncope Seizure (syncope can cause myoclonic movements…) Hypoglycemia, hypocapnea/hyperventilation Intoxication Vertebrobasilar TIA

Other etiologies that do not impair consciousness and are NOT syncope Drop attacks, falls, TIA from embolic source

Causes of Syncope

Neurally Mediated (up to 58% in some series)

Orthostatic/postural Cardiac arrhythmia (20-25%) Structural cardiac or pulmonary causes Cerebrovascular or psychiatric (1%) Unknown (18-30%)

Syncope in the Elderly

Usually multifactorial Often confounded by findings (orthostasis and

carotid hypersensitivity common and may be found and yet not be the cause…)

Prevalence up to 25% in nursing home population over age 70

Higher pretest probability of cardiac disease or arrhythmia

Importance of History and PE

Up to 70- 85% of patients in prospective studies had probable cause identified based upon history, physical exam and ecg

The History…

History of Heart DiseaseThe ONLY independent predictor of cardiac

cause (sens 95%, spec 45%)Absence of heart disease up to 97% specific

to rule out cardiac etiology (good NPV)

Neurally mediated (reflex)

TermsVasovagalVasodepressorNeurovascularNeurocardiogenicvasomotor

Who gets this?

We think of the young/healthy Older patients can (although often

complicated by comorbidities)

What is it? (Bezold-Jarisch phenomenon) The often repeated story

Excessive stimulation of mechanoreceptors due to forceful contraction of underfilled left ventricle leading to paradoxical signals to the CNS – causing change from vasoconstriction to vasodilation – causing drop in blood pressure and bradycardia

The more complicated story Disordered baroreflex function, paradoxical cerebral

autoregulation, endogenous vasodilators… we don’t really know….

Think neurally mediated…

Situations Warm environment, hot bath, post-exercise, prolonged

standing, large meals, early morning, valsalva, volume depletion, rising after prolonged bedrest, alcohol, medications

Symptoms Classic presyncopal symptoms

No underlying neurological or cardiac disease Prior history

Neurally mediated…sort of ….

Situational syncope Carotid sinus hypersensitivity

Situational Syncope

Situations… Cough Micturition Defecation Swallow Diving pain

Tussive or laughter syncope More common in obese men over 40, smokers with chronic cough

and COPD, children with asthma More on micturition syncope

Older men, early morning, exacerbated by medications

Carotid Sinus Hypersensitivity

HistoryStimulation of carotid area near barorecptor

(near bifurcation)Tight collar, neck pressure with head turning

or shaving/backing out of driveway

CSH…

Carotid massage3 second pause or > 50 mm drop in SBP

Three responses1. Cardioinhibitory (bradycardia/asystole)2. vasodepressor (hypotension)3. Mixed (features of both, most common)

Cardioinhibitory may benefit from pacing…

CSH…

Common in elderly, some concern that massage/testing may over diagnose

Also more likely to have positive response in patients with other degenerative neurological conditions such as Lewy body disease and parkinson’s

Pacing controversial, but may have role in select cases…

Summary: Reflex syncope (neural)

Vasovagal (neurally mediated) Situational Carotid sinus hypersensitivity

Postural Hypotension

Orthostatic Volume loss Blood loss Drop in blood pressure (SBP 20) with increase in HR

Autonomic

Common in elderly (10-30%) – presence may or may not be the cause of syncope

Often medication related (long list…)

Autonomic Insufficiency

Clinical Features Lack of tachycardic response; no respiratory variability of heart rate ED, urinary retention, gastric emptying delay

Causes Diabetes Paraneoplastic Amyloid Multiple Systems Atrophy (Shy-Drager) Primary Autonomic Failure Toxins Parkinson’s, Lewy body processes Guillain-Barre syndrome Spinal cord injury HIV

Cardiac: Arrhythmia

Bradycardia/asystole Sick sinus syndrome 2nd or 3rd degree AV blocks Pacemaker malfunction Have high suspicion in patients with bundle blocks…

Tachycardia Ventricular tachycardia Ventricular fibrillation SVT If you see afib, think sick sinus syndrome and

bradycardia/pauses…

Cardiac: Prolonged QT

QTc over 500 Lack of QT shortening with increased

heart rate (role of standing or exertional EKG)

Genetic or secondary to medications… Torsades

Brugada Syndrome

Triad RBBB pattern in right precordial leads Transient/persistent ST elevation in v1-v3 Sudden cardiac death

Structurally normal heart Association with young and healthy men from southeast asia

who present with sudden cardiac death Brugada sign may be asymptomatic High risk of sudden cardiac death in those who have syncope or

family history of sudden death (Indication for AICD based upon observational data)

Brugada Sign

Structural Cardiac or pulmonary causes Valvular disease (especially aortic stenosis) HOCM Cardiac masses (myxoma) Pericardial disease (tamponade or restrictive

processes) Prosthetic valve dysfunction Acute aortic dissection Pulmonary hypertension (exercise related) PE

Subclavian Steal Syndrome

Proximal subclavian artery stenosis Decreased blood flow to distal subclavian artery worsened with

exertion of arm Blood from vertebral artery on opposite side goes to basilar artery

and then down ipsilateral vertebral artery, away from brainstem, to serve as collateral for arm

Usually asymptomatic Atherosclerosis Symptoms of vertebrobasilar insufficiency (dizziness, vertigo,

diplopia, nystagmus) Rare to have permanent neurological deficits Diagnosis with dopplers, MRA Treatment: surgical revascularization, stents

Cerebrovascular

Syncope = global hypoperfusion Vertebrobasilar pathology or bilateral

carotid disease…

How do you evaluate the patient with syncope?

The Older Patient

Positive tests that are more common in the elderly and not necessarily the cause of the syncope: Orthostasis Positive carotid massage Positive tilt table testing

Up to 54% of older patients with syncope may have positive test…

Positive test in 10% of asymptomatic elderly!

Evaluation: History

Neurally mediated: Absence of heart disease Long history of recurrent syncope Associated factor (pain) Prolonged standing Associated n/v, diaphoresis, presyncopal symptoms After a meal CSH: turning head or pressure on neck

History…

OH:After standingProlonged standingPresence of autonomic insufficiency or

parkinson’sStanding after exertion

History… cardiovascular

Presence of structural heart disease (especially systolic dysfunction)

Family history of sudden death During exertion or supine (BIG FLAG) Swimming/diving into pool (prolonged QT) Abnormal EKG Syncope follows sudden onset of palpitations EKG:

QT Bundle blocks Afib, AV blocks Evidence of prior ischemia QRS over .12

Evaluation

EKG Telemetry Rule out ischemia (nursing home

patients…) Carotid sinus massage

Contraindicated in patients with prior TIA/stroke, bruits or known carotid stenosis

Evaluation

Orthostatics Echo

Tilt table testing

Passive or Isoproterenol Test: patient held in upright position (60-90 degrees), but

weightless to prevent muscles improving venous return; this leads to venous pooling, decreased venous return, and trigger of the neurally mediated reflex

Positive test: bradycardia or hypotension Passive testing: sensitivity only 70%, specificity 90-100% Isoproterenol: only 55% specificity Usually does not add much to the history and physical…

In-hospital monitoring

Yield low (under 20%) Recommended in high risk patients

Holter Monitoring

24-48 hours (no higher yield with longer) Low yield (1-2%) May be useful if symptoms are very

frequent

External Loop recorders

Loop memory that continuously records and deletes

Patient activates in response to symptoms (some devices also activated in response to rhythm)

Yield: ?25% when used for 4-6 weeks

Implantable Loop recorders

Duration up to 3 years Can be activated by patient or bystander or

automatically activated by arrhythmias May be cost effective to do earlier in the workup

than currently doing… Some series – 50-80 % patients with prior

unexplained syncope were able to have diagnosis

Electrophysiology Study (EP)

Underlying structural heart disease (especially depressed LV function)

Suspected bradycardia Patients with underlying bundle branch

block (look for development of His block with incremental atrial pacing)

Suspected tachycardia

Exercise Stress Testing

Patients with syncope with/after exertion Usually of low yield

Other evaluations…

Imaging, CTA Cardiac catheterization

Directed by history and physical…

Least useful tests…

Head CT with negative neuro exam (history should direct whether symptoms suggest stroke/TIA or syncope…)

EEG Carotid dopplers (see above…)

Risk Stratification

High Risk

Chest pain CHF Valvular disease History of ventricular arrhythmias EKG ischemic changes Prolonged QT c (over 500) Trifascicular block or pauses over 2 sec Cardiac devices Atrial fibrillation

High risk: ESC recommended hospitalization Known heart disease Syncope during exercise Trauma (facial) Family history sudden death Sudden palpitations prior to syncope Syncope while supine Multiple recent episodes

Intermediate risk

Age over 50 History of ischemic heart disease Family history of sudden death

Low risk

Age less than 50 No history of CV disease Normal EKG and exam Symptoms c/w neurally mediated or

vasovagal syncope Prior history of recurrent syncope with

symptoms c/w vasovagal etiology

Treatment: reflex syncope and orthostatic intolerance Lifestyle

Education, reassuranceAvoiding triggersManeuvers: supine posture, physical

counterpressure, crossing legs)Avoiding medications, ETOH Increasing fluids, salt intake

Reflex syncope

Tilt training Raising head of bed Progressively prolonged periods of upright posture

Meds: Beta blockers SSRI Ephedrine Midodrine No meds work that well…

Reflex syncope: Cardiac pacing

5 major RCTs, conflicting resultsSignificant selection biasLikely not justified unless spontaneous

bradycardia found on prolonged monitoring

Orthostatic intolerance

Stop possible medications Salt/fluid intake Compression stockings (ideally include

abdominal binders, so compliance low) Leg crossing/squatting with symptoms Midodrine (alpha-agonist): works better than in

patients with reflex syncope… Fludrocortisone (mineralcorticoid)

Indications for Pacing

Class IThird degree of advanced second degree AV

block with symptoms Bradycardia with symptoms Asystole over 3 seconds Escape rate less than 40 bpm After catheter ablation of AV junction Postoperative AVB

Pacing

Class II aAsymptomatic 3rd degree AVB or type II

second degree AVB with narrow QRS (class I if with a wide QRS)

Syncope with AVBDrug refractory afib….

AICD

Unexplained syncope and depressed LVEF (ischemic or nonischemic)

HOCM (II a) Brugada syndrome (II a unless high risk, such as

family history of sudden death) Long QT Patients with ischemic cardiomyopathy and

preserved LVEF but unexplained syncope (II b)

Back to the Pretest… 1. The ECG has the greatest value in its (NPV or PPV) in the diagnosis of a

cardiac etiology for syncope 2. History: 75 year old man reports presyncopal symptoms that occur while he

is driving backwards out of his driveway in the morning. This suggests … 3. History: an 80 year old man reports an episode of syncope that occurred

after doing arm exercises for a rotator cuff injury. This suggest… 4. The only independent predictor of a cardiac etiology of syncope is a past

history of … 5. ____ is a neurodegenerative disease characterized by profound autonomic

insufficiency and parkinsonian features on exam 6. An 82 year old man presents with postural hypotension, an idiopathic

peripheral neuropathy, significant proteinuria and your attending orders a rectal biopsy to look for____

7. Name 3 causes of “situational syncope” 8. Older patients are more likely to have positive a. tilt table tests b. carotid

sinus massage c. orthostatic hypotension d. all of the above

Answers to Pretest…

1. NPV 2. Carotid Hypersensitivity 3. Subclavian steal syndrome 4. Cardiac history 5. Multiple Systems Atrophy (shy-drager) 6. amyloid 7. micturition, defecation, cough, swallow 8. all of the above 9. bonus: brugada syndrome

Selected References Benditt DG, VanDjjk JG, Sutton R. Syncope: Curr Prob Cardiol 2004; 29(4): 152-229 Epstein AE. An update on implantable cardioverter-defibrillator guidelines. Curr Opin

Cardiology 2004; 19(1): 23-25 Littman L et al. Brugada syndrome and Brugada sign. Am Heart J 2003; 145(5): 768-

778 Raj S, Sheldon RS. Role of pacemaker in treating neurocardiogenic syncope. Curr

Opinion Cardiol 2003; 18: 47-52 Gregoratos G, Cheitlin MD, Conill A. ACC/AHA guidelines for implantation of cardiac

pacemakers and antiarrthythmia devices: executive summary: a report of the American College of Cardiology/Am Heart Assoc Task Force on Practice Guidelines. Circulation. 1998; 97: 1325-1335

Connolly SJ et al. The North American Vasovagal Pacemaker Study. J Am Coll Cardiol 1999; 33: 16-20

DiGirolamo et al. Effects of paroxetine on refractory vasovagal syncope. J Am Coll Cardiol 1999; 33: 1227-30

Sutton R et al. Dual chamber pacing in the treatment of neurally mediated tilt-positive cardioinhibitory syncope (VASIS). Circulation 2000; 102: 294-299

Selected References…

Krahn Ad et al. Use of the implantable loop recorder in evaluation of patients with unexplained syncope

Kapoor WN. Current evaluation and management of syncope. Circulation 2002; 106: 1606

Alboni P et al. Diagnostic Value of history in patients with syncope. J Am Coll Cardiol 2001; 37: 1921

Kapoor et al. Evaluation and outcome of patients with syncope. Medicine 1990; 69: 160

Linzer et al. Diagnosing syncope: part I. Ann Int med 1997; 126:989

Linzer et al. Diagnosing syncope: part II. Ann Int Med 1997; 127: 76

Primary References:

Chen, LY et al. Management of syncope in adults: an update. Mayo Clin Proc, 2008: 83: 1280-93.

Weimer L, Pezhman Z. Neurological aspects of syncope and orthostatic intolerance. Med Clin N Am 93 (2009) 427-449.

Strickberger et al. AHA/ACCF statement on the evaluation of syncope, Circulation 2006.

Moya et al. Guidelines for the diagnosis and management of syncope, task force from the ESC. Eur Heart J (2009)30, 2631-2671.