Syncope: Hospital Evaluation

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Syncope: Hospital Evalua7on

Brad Hendricks DO Hospitalist-‐Riverside Walter-‐Read Hospital

WVSOM Summer Seminar

No Disclosures

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Objec7ves

1. Define Syncope

2. Epidemiology

3. Types of Syncope

4. Risk Stra7fica7on

5. Explana7on of Hospital Evalua7on

Objec7ves

1.  Define Syncope

2. Epidemiology




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Defini7on

● Transient ● Loss of Consciousness ● Loss of Postural Tone ● Spontaneous Recovery

Objec7ves

1. Define Syncope

2.  Epidemiology




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Epidemiology ● 3% Emergency Department visits ● Up to 6% of Hospital Admissions ● Cost close to 2 Billion dollars per year ● Median peak of first syncope is around 15 years ● Sharp increase in incidence aXer 70 years ● 5% in females ages 20 to 29 ● Up to 50% in females aged 80 and above

Objec7ves

1. Define Syncope

2. Epidemiology

3.  Types of Syncope



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Types of Syncope

•  Cardiovascular

•  Neurocardiogenic (many names)

•  Orthosta7c

•  Neurologic

Cardiovascular-‐ Structural

•  Pulmonary embolism •  Pulmonary hypertension •  Mitral valvular stenosis •  Myocardial infarc7on (large) •  Pericardial constric7on or tamponade •  Aor7c ou_low tract obstruc7on •  Aor7c valvular stenosis •  Hypertrophic obstruc7ve cardiomyopathy

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Cardiovascular-‐ Arrhythmias

Bradyarrhythmias

Sinus Bradycardia Sick Sinus Syndrome

AV Block Pacer Malfunc7on Drug induced

Tachyarrhythmias

Supraventricular Tachycardia Atrial Fibrilla7on

Wolff-‐Parkonson-‐White syndrome Brugada syndrome

Ventricular Tachycardia Torsades de Pointes

Wolff-‐Parkinson White Syndrome

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Brugada Syndrome

Torsades de Pointes

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Neurocardiogenic Vasovagal

• Most common cause of syncope • Diagnosis made with History • Pathophysiology: Ini7ally Sympathe@c response (Palp, anxiety, swea7ng) Then Sympathe@c withdrawal (Vasodila7on) Followed by Parasympathe@c ac@vity (brady,nausea) • Frequently recurrent • OXen preceded by presyncopal prodrome las7ng

seconds to minutes. • Rarely occur in supine posi7on

Orthosta7c • Orthosta7c Hypotension is an excessive fall in blood pressure when an upright posi7on is assumed. • Defined as a drop of >20 mmHg systolic, 10 mmHg diastolic Volume Deple@on: -‐ inadequate fluid intake -‐ excessive volume loss Drug/medica@on induced: -‐ etoh, vasodilators, diure7cs, β-blockers, etc. Primary Autonomic Failure: -‐ mul7ple system atrophy, parkinson’s ds, lewy body demen7a Secondary Autonomic Failure: -‐ diabetes, amyloidosis, spinal cord injuries

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Neurologic • Rarely the primary cause of syncope. • Pa@ents with loss of consciousness with persistent neurologic deficits or altered mental status are not true syncope. • Brain-‐stem ischemia, subclavian steal, basilar artery migraines. Syncope mimics:

Seizure Subarachnoid hemorrhage Ventricular obstruc7on

Objec7ves

1. Define Syncope

2. Epidemiology


4.  Risk Stra@fica@on


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Risk Stra7fica7on San Francisco Rule:

1) Abnormal ECG or Cardiac Monitoring 2) Systolic Blood Pressure < 90mmHg 3) Hematocrit < 30% 4) CHF (at presenta7on or history of) 5) History of Shortness of Breath

• Included 12 studies with total 5316 patients • Nine studies were prospective and three were retrospective • Sensitivity 87%, Specificity 52% • Intended to identify patient at low risk of short-term serious outcomes.

C-‐ CHF hx H-‐ Hematocrit E-‐ ECG S-‐ SOB S-‐ SBP

Risk Stra7fica7on The ROSE Rule: (Risk Stra@fica@on Of Syncope in Emergency Department)

1) Brain Natriure7c Pep7de >300 pg/mL 2) Stool Posi7ve for Occult Blood 3) Oxygen Satura7on < 94% on room air on ini7al

presenta7on 4) Hemoglobin < 90 g/L 5) Chest Pain at the 7me of syncope 6) Bradycardia (HR < 50 bpm)

• ED based single center study • Edinburgh UK • Analyzed 529 pts older than 16 yrs • Prospective trial • 87% Sensitivity, 66% Specificity, 99% Negative Predictive Value

B-‐ BNP R-‐ rectal A-‐ anemia

C-‐ CP E-‐ ECG S-‐ Sats

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Objec7ves

1. Define Syncope

2. Epidemiology



5.  Explana@on of Hospital Evalua@on

Evalua7on • The primary purpose of the evalua7on of the pa7ent with syncope is to determine whether the pa7ent is at increased risk of death. Step 1:

Detailed History

“ Live neither in the past nor in the future, but let each day’s work absorb your en7re energies, and sa7sfy your widest ambi7on.” – Sir William Osler

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History ● New onset vs recurrent ● Prodrome ● Recent medica7on changes ● Observa7ons of onlookers ● Tonic-‐clonic/seizure like ac7vity ● Focal neurological changes/aura/Premoni7ons/pos7c7cal confusion ● Associated with turning head/ posi7on changes

History cont.

● Past Medical History: MI Head Trauma arrhythmia

● Family History

Sudden Death arrhythmia

● Social History

Drugs Alcohol

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Evalua7on

Step 2:

Physical Exam ● Vital signs including bedside 7lt ● Complete cardiac/neurological examina7on

“To have striven, to have made the effort, to have been true to certain ideals-‐ this alone is worth the struggle.” – Sir William Osler

Evalua7on Step 3:

Electrocardiogram (EKG) ● Inexpensive ● Informa7on on rhythm, AV conduc7on, nonsustained ectopy, etc. ● Diagnos7c in approximately 5%

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Echocardiogram ● Few studies have evaluated its u7lity -‐  Retrospec7ve Chart review Mean Age 58 yrs

Jan 2011 through Mar 2012 40 % Men 198 Adult pa7ents met inclusion criteria 50% Hispanic Bronx, NY Results: Correla7on between NML ECG and ECHO p<0.001 -‐  Retrospec7ve Cohort: 323 consecu7ve ED observa7on pa7ents Over 18 months Presen7ng with syncope Compared pa7ent with normal ECG to those with abnormal ECG Echo performed Results: No pa7ents with normal ECG (235) has structural heart abnormali7es.

Caro7d Duplex ● A low yield study for syncope evalua7on ● European Guidelines recommend against use to evaluate syncope ● US Guidelines recommend in serng of focal neurologic symptoms or cervical bruits.

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Stress test ● For suspected Ischemia ● Recommended for unexplained syncope ● Exer7on related syncope ● Exer7on induced tachyarrhythmia ● May need to get Echo prior to stress

Con7nuous Telemetry ● Low Yield ● $326 per day ● 24 hour Holter Monitor -‐ 4% Posi7ve Yield -‐ Organic heart disease, abnml EKG, high susp for arrhythmia ● External Loop Recorder -‐ 13% Posi7ve Yield, Suspicion for arrhythmia -‐ Frequent syncope, either no organic HD or organic heart DS/abnml EKG w/ nega7ve cardiac work-‐up ● Insertable Loop Recorder -‐ 27% Posi7ve Yield -‐ Nega7ve cardiac work-‐up, infrequent syncope, nega7ve 7lt

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Tilt Table Tes7ng ● Aids to establish diagnosis of neurocardiogenic syncope ● Sensi7vity ranges 26-‐80% Specificity approximately 90% ● Concerns about reproducibility ( 15-‐35%) ● In pa7ents with nega7ve evalua7on, the pretest probability that the diagnosis is neurocardiogenic syncope is high, so head-‐up 7lt table tes7ng contributes liule to establishing the diagnosis.

CT/MRI

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CT/MRI ● Low Yield ● Most help if neurologic deficit or complaint, Trauma above the clavicles, or warfarin therapy. ● Can be difficult to differen7ate syncope from epilepsy based predominantly clinical history ● Over interpreta7on of clinical and neuroimaging may occur in a nonspecific approach

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Review

● Detailed H&P/Exam, EKG, Orthosta7cs on every one ● Purpose is to iden7fy those at increased risk for death ● Majority don’t need hospitaliza7on -‐Risk Stra7fica7on Tools ● Choose studies wisely -‐ Caro7d Duplex not helpful -‐ Echo typically not helpful -‐ CT or MRI only if neurologic deficits -‐ Stress Test-‐ It’s up to you.

Thank You

Happy 3rd Birthday

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References 1.  Ray J, Kusumoto F, Nora G. Syncope. Journal of Intensive Care Medicine. 2016; 31:no.

2: 79-‐93. 2.  Kenny RA, Bhangu J, King-‐Kallimanis B. Epidemiology of Syncopy/Collapse in Younger and Older Western Pa7ent Popula7ons. Progress in Cardiovascular Diseases. Jan-‐Feb 2013, Vol.55(4):357-‐363. 3.  Fauci A, Braunwald E, et al. Harrison’s Principles of Internal Medicine. 2008, Edi7on 17: 139-‐143 4.  Strickberger S, Benson DW, et al. AHA/ACCF Scien7fic Statement of the Evalua7on of Syncope. Circula7on. 2006;113: 316-‐327. 5.  Downs M, Cowan C, Campbell J. Does Head CT Assist in the Diagnosis of an Adult with

Syncope? Evidence-‐Based Prac7ce. 2014; 17 (12): 1-‐2. 6.  Puppala V, Dickinson O, Bendiu D. Syncope: Classifica7on and Risk Stra7fica7on.

Journal of Cardiology. 2014. Vol 63 (3): 171-‐177. 7.  Saccilouo R, Nickel C, Koller M. San Francisco Syncope Rule to Predict Short-‐Term

Serious Outcomes: A Systemic Review. Canadian Medical Associa7on Journal. 2011. 183(15):1116-‐1126.

8.  Goldman L, Ausiello D, et al. Cecil Medicine. 2008. Edi7on 23:2687-‐2691. 9.  Tin7nalli J, et al. Tin7nalli’s Emergency Medicine. 2011. Edi7on 7: 399-‐405.

References-‐cont. 10.  Atoui M, Gonzalez C, Bhandari M, et.al. Echocardiogram in the Evalua7on of Pa7ents with Syncope and Normal Electrocardiogram: Do We Need It. Circula7on. 2013; 128: A18522. 11.  Anderson K. Cardiac Evalua7on for Structural Abnormali7es May Not Be Required in Pa7ents Presen7ng With Syncope and a Normal ECG Result in Observa7on Unit Serng. Annuals Emergency Medicine. 2012; 60: 478-‐484. 12. Kadian -‐Dodov D, Papolos A, Olin J. Diagnos7c U7lity of Caro7d Artery Ultrasonography in the Evalua7on of Syncope: A Good Test for the Wrong Reason. European Heart Journal-‐ Cardiovascular Imaging. 2014; doi:10.1093/ehjci/jeu315. 13. Kapoor W. Current Evalua7on and Management of Syncope. Circula7on. 2002; 106:1606-‐1609 14. Grossman S, Fischer C, et.al. The Yield of Head CT in Syncope: A Pilot Study. Internal and Emergency Medicine. 2007; Vol 2: (1), pp 46-‐49 15. Fauouch J, Bonaventura C, et.al. Over-‐Interpreta7on of Electoclinical and Neuroimaging Findings in Syncope Misdiagnosed as Epilep7c Seizures. Epilep7c Disord. 2007; 9 (2): 170-‐ 173 16.

Syncope: Hospital Evaluation

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