Syncope Initial Evaluation and Management - …/media/Images/Swedish/CME1/SyllabusPDFs/...1 Syncope...

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Syncope

Initial Evaluation and Management

John L. Petersen II, MD, MHS

July 14, 2017

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Conflicts

• Stocks/Ownership

– Veravanti

• Speakers Bureau

– None

• Education Grants

– St Jude Medical

• Research Grants/Funding

– Abbott Vascular, Baxter, Biosensors, Reva Medical, Keystone

Medical, NIH

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Question 1

• According to the ACC/AHA Guidelines, an appropriate

initial evaluation for all patients with syncope would

include

A. H and P Alone

B. H and P and ECG

C. H and P, ECG, and Transthoracic Echo

D. H and P, ECG, and Ambulatory ECG Monitor

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Question 2

• Which of the following is not a prognosticator of

morbidity and mortality among patients with syncope

A. Age

B. Nausea and Vomiting

C. Palpitations

D. Cerebral Vascular Disease

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Question 3

• Even with dedicated evaluations to investigate the

cause, the % of cases for which a cause cannot be

established is:

A. 70-80%

B. 50-60%

C. 20-40%

D. 1-10%

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Objectives

• Discuss Definition and Causes of Syncope and other

Causes of Loss of Consciousness

• Review Initial Diagnostic Evaluation

• Identify Appropriate Patients for Additional Studies or

Referral for Specialty Evaluation

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Overview

• Syncope

– Definition

– Classification of Causes

– Non Cardiac Causes of Loss of Consciousness

• Initial Evaluation and Risk Stratification

– History Elements

– Physical Exam Elements

– ECG Elements

– High Risk Features

• Appropriate Patients for Specialty Referral

– Which patients

– What Kind of Testing to Expect 7

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Syncope

Abrupt, transient, complete loss of consciousness,

associated with inability to maintain postural tone, with

rapid and spontaneous recovery

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What it is and what it is not

Syncope

• Orthostatic Hypotension

• Cardiac

– Bradycardia, tachycardia

– Structural Heart Disease

– Dissection

– Global Ischemia

– Heart Failure

• Pulmonary

– PE, pulmonary hypertension

• Reflex Syncope

– Vasovagal

– Carotid Sinus Syndrome

– Situational

– POTS

Not Syncope

• Coma

• Intoxication / Overdose

• Metabolic Derangements

• Trauma

• Massive Stroke

• Psychogenic Pseudo-

syncope

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Epidemiology

Syncope is common ~ 20% of people will experience it

during a lifetime

The incidence increases with age > 70

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Epidemiology

• Syncope is common ~ 20% of people will experience it

during a lifetime

• The incidence increases with age > 70

• Females are more likely to have syncope than males

• BUT – males are more likely to have high risk syncope

• The most common cause is reflex mediated syncope –

– Otherwise known as Vasovagal Syncope or Neurocardiogenic

syncope

• The etiology varies between studied but between 20-

40% of case no cause is identified

– BUT this has a good prognosis

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Common Scenario

• 52 y.o. male patient presents to office on a Tuesday.

Over the weekend, had a passing out spell in the

afternoon at a barbeque. He woke up within a minute

or two and then felt better. The rest of the weekend

was uneventful

What do you do next?

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General Principles

Transient loss of consciousness*

Suspected

syncope

Yes

Evaluation as clinically

indicatedNo

Risk assessmentCause of syncope

certain

Cause of syncope

uncertain

Further evaluationTreatment

Initial evaluation:

history, physical examination,

and ECG

(Class I)

Syncope Initial Evaluation

*See relevant terms and definitions in Table 3.

Colors correspond to Class of Recommendation in Table 1. This figure shows the

general principles for initial evaluation of all patients after an episode of syncope.

ECG indicates electrocardiogram.

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History and Physical Examination

COR LOE Recommendation

I B-NRA detailed history and physical examination should be

performed in patients with syncope.

Electrocardiography


I B-NRIn the initial evaluation of patients with syncope, a

resting 12-lead ECG is useful.

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History

• So you say I need to do a good H and P

– What does that mean? Ask them about childhood

immunizations? Do a Weber-Rinne test?

• Targeted History

– Description of Episode(s)

• Important for clarifying etiology

– Number of Episodes

– Medications

– Comorbid Conditions

– Family History

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Description of the Event

• Situation

– Decreased volume status,

ethanol and substance use

– Exercise/Exertion

– Anxiety provoking situation

– Fatigue, Sleep Depravation

– Postural changes

– Concomitant Body Functions

(Coughing, Valsalva,

Micturition, Defecation,

Deglutination)

• Prodrome

– Duration

– Nausea, Vomiting

– Flushing, Pallor

– Palpitations

– Dyspnea

• Recovery

– Bladder, Bowel

Function

– Trauma

– Evidence of Bleeding

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Past History

• Prior Episodes

– Similarity and Age of Onset

• Medications

– Cardiac Medications

– Psychiatric Medications

– Antibiotics and other QT prolonging medications

• Known Cardiac History and Cardiac ROS

• Known Neurological History and Neurological ROS

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Family History

• Cardiac Family History

– Early Atherosclerosis

– Cardiomyopathy

– Arrhythmia / ICD

placement

– Sudden Death

– Hypercoagulable State

– Aortic Dissection

• Neurologic Family History

– Seizures

– Degenerative Diseases

– Neuropathy

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Detailed Exam

• Cardiac Exam

– Murmurs, Rhythm, Signs of R and L Heart Failure

– Bruits and evidence of atherosclerotic vascular disease

– Orthostatics – Including 3 minute recheck

• Neurological Exam

– Evidence of Degenerative Neurologic Disease

– Strength, Sensation, Balance, Tremors

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ECG

• What to look for:

– Rhythm – Heart block, Atrial Arrhythmias, Wide Complex

Rhythm

– Conduction Disease – LBBB, RBBB, etc

– Pre-Excitation (WPW or short PR interval)

– Repolarization Abnormalities (hypertrophic CM)

– Chamber enlargement, including LAE

– Prior MI

– Long QT syndrome (QTc 500 msec without obvious cause)

– Brugada syndrome

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WPW (Wolfe-Parkinson-White)

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Hypertrophic Cardiomyopathy

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Long QT Syndrome

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Brugada Syndrome

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Risk Assessment

COR LOE Recommendations

I B-NR

Evaluation of the cause and assessment for the short-

and long-term morbidity and mortality risk of syncope

are recommended.

IIb B-NRUse of risk stratification scores may be reasonable in

the management of patients with syncope.

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High/Moderate Risk – Short Term (< 30 days)

• History – Male

– Age > 60

– No prodrome

– Palpitations

– Exertion


– Heart Failure

– Cerebrovascular Disease

– Family History of Sudden

Death

– Trauma

• Physical Exam / Lab

– Bleeding

– Persistently Abnormal

Vital Signs

– Abnormal ECG

– Positive Troponin

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High/Moderate Risk – Long Term (> 30 days)

• History– Male

– Age

– Absence of nausea/vomiting

– Ventricular Arrhythmia

– Cancer


– Heart Failure

– Cerebrovascular Disease

– Diabetes

– High CHADS2-Vasc

• Laboratory – Abnormal ECG

– Renal Failure

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Back to our Patient

• 52 yo male passed out at a barbeque in the afternoon

– Ask about situation, prodrome, recovery, past history and

family history and perform exam

– Likely outside, warm

– Tells you he felt flush and bystanders said he looked pale.

– May have involved ethanol consumption and limited water

intake

– If no cardiac or neuro history, no risk factors, no family history,

Exam, vitals, orthostatics and ECG normal

– His only real risk factor is being male – so no further work up.

– Educate the patient about volume and dehydration

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What if?

• He says:

– Father had MI at 48

– There were palpitations preceding the event

– It occurred moving a heavy box of supplies from the pickup to

the picnic table

– ECG has findings of LVH and left atrial enlargement

– This is not low risk

• Needs further evaluation

• Ambulatory ECG and Echo to start, consider stress test based on

additional symptoms of exertion

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Examples Of High Risk Conditions

Warranting Hospitalization

• Cardiac Arrhythmia

– Sustained VT

– High Degree AV block

– Symptomatic Bradycardia

– Sinus Pauses

– Symptomatic SVT

– ICD Malfunction

– Genetic Conditions

• Other Cardiac

– Coronary Ischemia

– Severe AS

– Cardiac Tamponade

– Hypertrophic cardiomyopathy

– Severe prosthetic valve

dysfunction

– Pulmonary embolism

– Aortic Dissection

– Acute heart Failure

– Sytolic LV dysufnction

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• Other Non Cardiac

– Severe Anemia / Bleeding

– Major Trauma

– Persistent Vital Sign

Abnormalities

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Patient Disposition After Initial Evaluation for Syncope

Syncope initial evaluation

Manage presumptive

reflex-mediated

syncope in

outpatient setting

(Class IIa)

Inpatient evaluation

(Class I)

Yes

Serious

medical conditions

present?

(Table 7)

Structured ED

observation protocol

for intermediate-

risk pts

(Class IIa)

Manage selected pts

with suspected

cardiac syncope in

outpatient setting

(Class IIb)

No

Colors correspond to Class of Recommendation in Table 1.

ED indicates emergency department; pts, patients.

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Disposition After Initial Evaluation


I B-NR

Hospital evaluation and treatment are recommended for

patients presenting with syncope who have a serious

medical condition potentially relevant to the cause of

syncope identified during initial evaluation.

IIa C-LDIt is reasonable to manage patients with presumptive

reflex-mediated syncope in the outpatient setting in the

absence of serious medical conditions.

IIa B-R

In intermediate-risk patients with an unclear cause of

syncope, use of a structured ED observation protocol

can be effective in reducing hospital admission.

IIb C-LD

It may be reasonable to manage selected patients with

suspected cardiac syncope in the outpatient setting in

the absence of serious medical condition.

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When to Refer?

• Referral

– Clear evidence of

cardiac disease or

assessment that finds

patient is at risk for

cardiac disease

– Clear evidence

neurologic disease

– Intermediate risk –

reflex syncope with

other findings

– No findings at all – not

clearly reflex mediated

• When Not to Refer

– No findings of Cardiac

or Neuro disease

– No orthostasis

– ECG negative

– No family history

– Event history consistent

with reflex mediated

syncope (OH,

Vasovagal)

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Additional Evaluation and Diagnosis

Initial

evaluation

suggests reflex

syncope

Initial evaluation

unclear

Targeted blood

testing

(Class IIa)†

Initial

evaluation

suggests

neurogenic OH

Initial

evaluation

suggests CV

abnormalities

Referral for

autonomic

evaluation

(Class IIa)†

TTE

(Class IIa)†

Stress testing

(Class IIa)†

Tilt-table

testing

(Class IIa)†

Cardiac monitor

selected based

on frequency

and nature

(Class I)

Implantable

cardiac monitor

(Class IIa)†

Ambulatory

external cardiac

monitor

(Class IIa)†

Options

Initial evaluation:

history, physical exam, ECG

(Class I)

EPS

(Class IIa)†

Initial evaluation

clear

MRI or CT

(Class Ilb)†

No additional

evaluation

needed*

Options

Syncope additional evaluation and diagnosis


*Applies to patients after a normal initial evaluation without significant injury or

cardiovascular morbidities; patients followed up by primary care physician as needed.

†In selected patients (see Section 1.4).

CT indicates computed tomography; CV, cardiovascular; ECG, electrocardiogram; EPS,

electrophysiological study; MRI, magnetic resonance imaging; OH, orthostatic

hypotension; and TTE, transthoracic echocardiography.

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What about other tests?

• Labs

• Echo

• Stress Testing

• Holter and or Ambulatory ECG monitoring

• CT head / MRI Head

• EEG

• Carotid Ultrasound

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IIa B-NR

Targeted blood tests are reasonable in the evaluation

of selected patients with syncope identified on the

basis of clinical assessment from history, physical

examination, and ECG.

IIb C-LD

Usefulness of brain natriuretic peptide and high-

sensitivity troponin measurement is uncertain in

patients for whom a cardiac cause of syncope is

suspected.

III: No

BenefitB-R

Routine and comprehensive laboratory testing is not

useful in the evaluation of patients with syncope.

Blood Testing

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Cardiac Imaging


IIa B-NR

Transthoracic echocardiography can be useful in selected

patients presenting with syncope if structural heart

disease is suspected.

IIb B-NRCT or MRI may be useful in selected patients presenting

with syncope of suspected cardiac etiology.

III: No

BenefitB-R

Routine cardiac imaging is not useful in the evaluation of

patients with syncope unless cardiac etiology is

suspected on the basis of an initial evaluation, including

history, physical examination, or ECG.

Cardiovascular Testing

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Stress Testing


IIa C-LD

Exercise stress testing can be useful to establish the

cause of syncope in selected patients who experience

syncope or presyncope during exertion.

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Cardiac Monitoring


I C-EOThe choice of a specific cardiac monitor should be

determined on the basis of the frequency and nature of

syncope events.

IIa B-NR

To evaluate selected ambulatory patients with syncope of

suspected arrhythmic etiology, the following external

cardiac monitoring approaches can be useful:

1. Holter monitor

2. Transtelephonic monitor

3. External loop recorder

4. Patch recorder

5. Mobile cardiac outpatient telemetry.

IIa B-RTo evaluate selected ambulatory patients with syncope of

suspected arrhythmic etiology, an ICM can be useful.

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Neurological and Imaging Diagnostics


IIa C-LD

Simultaneous monitoring of an EEG and hemodynamic

parameters during tilt-table testing can be useful to

distinguish among syncope, pseudosyncope, and

epilepsy.

III: No

BenefitB-NR

MRI and CT of the head are not recommended in the

routine evaluation of patients with syncope in the absence

of focal neurological findings or head injury that support

further evaluation.

III: No

BenefitB-NR

Carotid artery imaging is not recommended in the routine

evaluation of patients with syncope in the absence of

focal neurological findings that support further evaluation.

III: No

BenefitB-NR

Routine recording of an EEG is not recommended in the

evaluation of patients with syncope in the absence of

specific neurological features suggestive of a seizure.

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I C-EOPatient education on the diagnosis and prognosis of VVS

is recommended.

IIa B-R

Physical counter-pressure maneuvers can be useful in

patients with VVS who have a sufficiently long prodromal

period.

IIa B-RMidodrine is reasonable in patients with recurrent VVS

with no history of hypertension, HF, or urinary retention.

IIb B-RThe usefulness of orthostatic training is uncertain in

patients with frequent VVS.

IIb B-R

Fludrocortisone might be reasonable for patients with

recurrent VVS and inadequate response to salt and fluid

intake, unless contraindicated.

Reflex Conditions

Vasovagal Syncope

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IIb B-NRBeta blockers might be reasonable in patients 42 years of

age or older with recurrent VVS.

IIb C-LD

Encouraging increased salt and fluid intake may be

reasonable in selected patients with VVS, unless

contraindicated.

IIb C-LD

In selected patients with VVS, it may be reasonable to

reduce or withdraw medications that cause hypotension

when appropriate.

IIb C-LDIn patients with recurrent VVS, a selective serotonin

reuptake inhibitor might be considered.

Vasovagal Syncope (cont.)

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Vasovagal Syncope

VVS

Education on

diagnosis and prognosis

(Class I)

Counter pressure

maneuvers

(Class IIa)

Salt and fluid

intake

(Class IIb)

VVS recurs

Selected serotonin

reuptake inhibitors

(Class IIb)

Midodrine

(Class IIa)

Beta blocker

(in patients >42 y)

(Class IIb)

Orthostatic training

(Class IIb)

Dual-chamber

pacemaker therapy

(Class IIb)

Fludrocortisone

(Class IIb)

Options

Options


VVS indicates vasovagal syncope.

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Orthostatic

Hypotension

Colors correspond to Class

of Recommendation in

Table 1.

BP indicates blood pressure;

OH, orthostatic hypotension.

Continue to

evaluate

Syncope of suspected OH origin

Postural decrease in

BP ≥20/10 mm HgNo

Neurogenic OH

Compression

garments

(Class IIa)

Counter-pressure

maneuvers

(Class IIa)

Fludrocortisone

(Class IIa)

Midodrine

(Class IIa)

Droxidopa

(Class IIa)

Pydridostigmine

(Class IIb)

Drugs Dehydration

Options

Acute water

ingestion

(Class I)

Reduce or withdraw

medications

(Class IIa)

Reduce or withdraw

medications

(Class IIa)

Octreotide

(Class IIb)

Acute water

ingestion

(Class I)

Increase salt

and fluid intake

(Class IIb)

Increase salt and

fluid intake

(Class IIa)

Therapy options in

selected patients

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Conclusions

• Syncope is common and incidence increases with age

• It is important to distinguish high risk and low risk

causes

• This is based mostly on history, exam, and ECG.

• Patients with clear reflex mediated syncope can be

managed conservatively

• Patients with clear cardiac or neurologic disease

should be referred – and possibly admitted

• Patients with intermediate risk should be referred with

directed additional testing based on findings

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Question 1



include

A. H and P Alone

B. H and P and ECG



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47

Question 1



include

A. H and P Alone

B. H and P and ECG



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Question 2



A. Age


C. Palpitations


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Question 2



A. Age


C. Palpitations


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Question 3



established is:

A. 70-80%

B. 50-60%

C. 20-40%

D. 1-10%

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Question 3



established is:

A. 70-80%

B. 50-60%

C. 20-40%

D. 1-10%

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Syncope Initial Evaluation and Management - …/media/Images/Swedish/CME1/SyllabusPDFs/...1 Syncope...

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