SYNCOPE

Tim Evans

July 30, 2014

Syncope Background• Syncope Podcast—Steve Carroll, DO• Syncope—Saklani P, Circulation. 2013;127:1330-1339• Clinical Policy: Critical Issues in the Evaluation and Management of

Adult Patients Presenting to the Emergency Department with Syncope—ACEP Clinical Policies Subcommittee, Ann Emerg Med. 2007;49:431-444

• AHA/ACCF Scientific Statement on the Evaluation of Syncope: From the American Heart Association Councils on Clinical Cardiology, etc, Circulation. 2006;113:316-327

A PROSPECTIVE EVALUATION AND FOLLOW-UP OF PATIENTS WITH SYNCOPE—Kapoor WN, et al: N Eng J Med 1983; 309: 197-204

• Results• 204 patients evaluated and followed for up to more than one year

—97 patients never found to have an etiology of syncope identified• Tests performed

• Labs in every patient—no cause for syncope found• ECG in every patient—12 causes for syncope found,

• Sinus bradycardia (2) • Complete heart block (3)• Pacemaker malfunction (1)• MI (2)• Sinus pause (1)• V Tach (3)

A PROSPECTIVE EVALUATION AND FOLLOW-UP OF PATIENTS WITH SYNCOPE

• Results (continued)• Tests performed

• Prolonged electrocardiographic monitoring—190 patients, 29 causes for syncope found• Sinus pauses greater than 2 seconds (8)• Symptomatic sinus bradycardia (1)• V Tach (14)• A fib (2)• Symptomatic SVT (2)• Mobitz II AV block (2)

• Electrophysiologic Studies—23 patients, 3 inducible V Tach patients identified

• Cardiac cath—25 patients, 5 with aortic stenosis, 2 with pulmonary hypertension

• Cerebral angiography—11 patients, 2 with subclavian steal• EEG—101 patients, 3 with abnormalities, 1 perhaps causing seizures• CT scan head—65 patients, no cause of syncope found

A PROSPECTIVE EVALUATION AND FOLLOW-UP OF PATIENTS WITH SYNCOPE

• Diagnostic Studies that Determined Cause of Syncope• H+P—52• ECG—12• ECG monitoring—29• Electrophysiologic studies—3• Cardiac cath—7• Cerebral angiography—2• EEG--1

A PROSPECTIVE EVALUATION AND FOLLOW-UP OF PATIENTS WITH SYNCOPE

Cardiovascular Cause for Syncope—53 patients

• V Tach—20• Sick Sinus—10• Aortic Stenosis—5• SVT—3• Complete heart block—3• Bradycardia—2• Mobitz II AV block—2• MI—2• Pulm HTN—2• PE—1• Pacer malfunction—1• Carotid Sinus Syncope—1• Aortic Dissection--1

Non-cardiovascular Cause for Syncope—54 patients

• Situational Syncope—15• Orthostatic Syncope—14• Vasodepressor Syncope—10• Drug Induced—6• TIA—3• Seizure—3• Subclavian Steal-2• Conversion--1

Deaths During the Follow up PeriodCardiovascular cause (N=53)

Non cardiovascular cause (N=54)

Unknown Cause(N=97)

Sudden Death 11 2 3

Non sudden cardiovascular death

2 0 0

Death due to other underlying diseases

3 4 3

Mortality at 12 months

30 12 6.4

•The only difference between syncope and sudden death is that in one you wake up.

Detailed Patient history

• Circumstance of recent event• Eyewitness account• What was patient doing at

time of event?• Symptoms at onset of event

—was there a prodrome?• Position during event• Sequelae

• Circumstance of prior events

• Past Medical History• Cardiac• Neurologic

• Family History• Cardiac• Sudden Cardiac Death

• Medications

Drugs Commonly implicated in Syncope

• Antihypertensives• Beta Blockers• Cardiac glycosides• Diuretics• Antidysrhythmics• Nitrates

• Antipsychotics• Antidepressants• Phenothiazines

Antiparkinsonism

Alcohol

Cocaine

Physical Exam

• Vital signs• Orthostatic hypotension• Cardiovascular exam—murmurs? Heart failure?• Neurologic exam—focal deficits?• Evidence of trauma?• Carotid Sinus Massage

Risk Stratification tools for syncope• Bottom Line—no single decision rule is sufficiently

sensitive or specific to use in the ED

• But not useless—provide framework for clinical decision making

Decision Rules• Martin and Kapoor—history of arrhythmias, abnormal ecg, hx

of chf, age>45• San Francisco Syncope Rule—CHESS-hx chf, hct < 30, ecg

with changes or non-sinus rhythm, sbp<90, sob• Osservatorio Epidemiolgicalao sulla Sincope nel Lazio

(OESIL)—age>65, hx cardiovascular dx, syncope without prodrome, abnormal ecg—if 2 positive increased risk of sudden death

• Risk Stratification of Syncope in ED (ROSE)—bnp>300, brady <50, gi blood, anemia, cp, O2 sat <94—if one positive admit

• Boston Syncope Criteria-signs and symptoms of cad, cardiac hx, persistent abnormal vital signs in ED, volume depletion, conduction abnormalities, valvular heart disease by history or exam

• Evaluation of Guidelines in Syncope Study (EGSYS)—abnormal ecg, heart disease, palpitations before syncope, syncope with effort or supine, no prodrome, no precipitants

High Risk Criteria• Abnormal ECG—Bundle branch block or ivcd,

bradycardia or 1st degree block in absence of beta blockers or physical training, short PR, short or long QT, ischemia, infarction

• Suspicion of structural heart disease –hx or signs/symptoms of MI, CHF, valvular heart disease

• SOB• Syncope during exertion or with recumbency• SBP < 90• HCT < 30• Family hx of sudden cardiac death—particularly if

under age 50• Advanced age

Brugada Syndrome

Wolff Parkinson White

Syncope--Summary

• Do thorough H+P—this is where the diagnosis will be made

• Do an ECG—look for the obvious and the not so obvious—infarcts, abnormal intervals, right heart strain

• Limit labs—HCG in fertile females, not much else• Don’t do CT unless abnormal neuro or looking for traumatic injury

Is it true syncope? Transient LOC with return to baseline

neurologic function

History, examination, investigation of other

symptoms, ECG

Yes No (e.g.seizure, stroke, head trauma, other)

Appropriate management

Diagnosis established?

Yes No

Syncope with clear cause

Unexplained syncope

Risk stratificationSerious

cause?

Appropriate management; admission

Likely discharge

Cardiac syncope Arrhythmia Myocardial infarction Pericardial effusion Pulmonary embolism Neurologic syncope Subarachnoid hemorrhage Subclavian steal syndrome Transient ischemic attackSignificant hemorrhage GI/GU/Gyn bleed Trauma

Neurocardiogenic/vasovagal Vasomotor syncope Carotid hypersensitivity Situational syncopeMedication relatedOrthostatic hypotension

High-risk Criteria*

Low risk and asymptomatic

Discharge with follow-upAdmission for evaluation and cardiac monitoring*High-risk criteria: Abnormal ECG Suspicion of structural heart

disease, especially a history of CHF

HCT <30 Shortness of breath SBP <90 mmHg Family history of sudden

cardiac death Advanced age****There is no discrete age limit, and other factors such as cardiovascular risk play a greater role; age <45 appears to clearly be low risk if no other factors are present