SyncopeSyncope

What we will discuss?What we will discuss?

Background Background informationinformation

Evaluation of syncopeEvaluation of syncope Treatment of certain Treatment of certain

causes of syncopecauses of syncope Useful, practical Useful, practical

itemsitems

DefinitionDefinition

Sudden and brief loss of consciousnessSudden and brief loss of consciousness Associated with loss of postural toneAssociated with loss of postural tone Recovery is spontaneousRecovery is spontaneous A symptom and not a diseaseA symptom and not a disease

Scope of the problemScope of the problem

Occurs in 3-37% of general populationOccurs in 3-37% of general population 6% annual incidence amongst elderly 6% annual incidence amongst elderly

residents of long-term care institutionsresidents of long-term care institutions 3.5% of all ER visits3.5% of all ER visits 1-6% of all hospital admissions1-6% of all hospital admissions

Is it syncope?Is it syncope?

PresyncopePresyncope DizzinessDizziness VertigoVertigo Drop attacksDrop attacks SeizuresSeizures Cardiac arrestCardiac arrest

PathophysiologyPathophysiology

Sudden decrease in or brief cessation of Sudden decrease in or brief cessation of cerebral blood flow and nutrient delivery (seen cerebral blood flow and nutrient delivery (seen in all formsin all forms))

Mechanisms:Mechanisms: - Decrease in cardiac output, including loss of preload, mechanical - Decrease in cardiac output, including loss of preload, mechanical outflow obstruction, and arrhythmiasoutflow obstruction, and arrhythmias- Loss of vascular resistance, often by neurocardiogenic reflex - Loss of vascular resistance, often by neurocardiogenic reflex mechanismsmechanisms- Focal or generalized decrease in cerebral perfusion caused by - Focal or generalized decrease in cerebral perfusion caused by cerebrovascular diseasecerebrovascular disease- Causes in which cerebral blood flow is essentially normal, such as - Causes in which cerebral blood flow is essentially normal, such as hypoglycemia, hypoxia, and seizureshypoglycemia, hypoxia, and seizures

Neurocardiogenic reflex mechanismsNeurocardiogenic reflex mechanisms

Causes of SyncopeCauses of Syncope

More causes of syncopeMore causes of syncope

Kapoor, W. N. N Engl J Med 2000;343:1856-1862

Causes of Syncope

Diagnosing the causeDiagnosing the cause

History is keyHistory is key Presence of structural heart diseasePresence of structural heart disease Physical examPhysical exam EKGEKG

The findings from this initial assessment will The findings from this initial assessment will guide your evaluation.guide your evaluation.

Historical aspectsHistorical aspects

Number of episodesNumber of episodes Associated symptoms/ProdromeAssociated symptoms/Prodrome Preceding eventsPreceding events Witnessed appearanceWitnessed appearance Recovery or postevent periodRecovery or postevent period PMHx/Family hx/MedicationsPMHx/Family hx/Medications

More on historyMore on history

Number of episodesNumber of episodes

- Single episode or multiple episodes over many years vs. multiple - Single episode or multiple episodes over many years vs. multiple episodes over a short period timeepisodes over a short period time

Associated symptoms/ProdromeAssociated symptoms/Prodrome

- Dyspnea, angina, focal neurologic abnormalities- Dyspnea, angina, focal neurologic abnormalities

- Nausea, warmth, pallor, lightheadedness, diaphoresis- Nausea, warmth, pallor, lightheadedness, diaphoresis Preceding eventsPreceding events

- Coughing, eating, drinking cold liquid, urinating, defecating, - Coughing, eating, drinking cold liquid, urinating, defecating, exertionexertion

Recovery or postevent periodRecovery or postevent period

- Persistence of nausea, pallor, diaphoresis- Persistence of nausea, pallor, diaphoresis

- Significant neurologic changes or confusion- Significant neurologic changes or confusion

Other historical featuresOther historical features

AgeAge

- Young vs. elderly- Young vs. elderly PositionPosition

- Supine vs. standing- Supine vs. standing Duration of symptomsDuration of symptoms

- Brief vs. prolonged- Brief vs. prolonged InjuryInjury

- Tongue biting- Tongue biting

- Important to determine if syncope places individuals or - Important to determine if syncope places individuals or

others at riskothers at risk

Preexisting medical conditionsPreexisting medical conditions

Psychiatric illnessPsychiatric illness Diabetes mellitusDiabetes mellitus

- Orthostatic hypotension secondary to autonomic neuropathy- Orthostatic hypotension secondary to autonomic neuropathy

HTNHTN- Antihypertensive medications can result in syncope- Antihypertensive medications can result in syncope

Presence of heart diseasePresence of heart disease

Importance of heart diseaseImportance of heart disease

Only independent predictor of Only independent predictor of cardiac cause of syncope cardiac cause of syncope (sensitivity 95%, specificity (sensitivity 95%, specificity 45%)45%)

Most important factor for Most important factor for predicting risk of death and predicting risk of death and likelihood of arrhythmiaslikelihood of arrhythmias

Increased risk of death Increased risk of death regardless of the cause of regardless of the cause of syncopesyncope

Obtaining information from CardiologyObtaining information from Cardiology

Can page EKG tech (800-308-5890)Can page EKG tech (800-308-5890) Make copies of old EKG’s, echo reports, Make copies of old EKG’s, echo reports,

cath reports, clinic SF600’s (before CHCS-cath reports, clinic SF600’s (before CHCS-II)II)

If you are in the Cardiology clinic, can If you are in the Cardiology clinic, can obtain this information from front desk obtain this information from front desk area, record/storage room (code to door is area, record/storage room (code to door is 7843)7843)

Physical examinationPhysical examination

Vital signsVital signs

Heart rate, Orthostatics, RRHeart rate, Orthostatics, RR

Cardiac examCardiac exam

Systolic murmurs and physiologic maneuversSystolic murmurs and physiologic maneuvers

Neuro examNeuro exam

Focal signs, mental statusFocal signs, mental status

Carotid sinus massage Carotid sinus massage

Carotid sinus massageCarotid sinus massage

Each carotid palpated and auscultated for Each carotid palpated and auscultated for presence of bruits (test not performed in those presence of bruits (test not performed in those with evidence of carotid artery disease)with evidence of carotid artery disease)

Pressure applied to one carotid sinus for 2-3 secs Pressure applied to one carotid sinus for 2-3 secs with vigorous/circular movementswith vigorous/circular movements

Done with simultaneous EKG monitoringDone with simultaneous EKG monitoring Positive test if there is pause for Positive test if there is pause for >> 3 secs 3 secs Use cautiously in elderly patientsUse cautiously in elderly patients

EKG findingsEKG findings

Sinus bradycardiaSinus bradycardia AV nodal disease (2AV nodal disease (2ndnd or 3 or 3rdrd degree heart degree heart

block)block) Bundle branch and/or fascicular blockBundle branch and/or fascicular block Prolonged QT intervalProlonged QT interval

Presence of EKG findings does not prove causality unless Presence of EKG findings does not prove causality unless findings are captured during actual event/symptoms.findings are captured during actual event/symptoms.

Other EKG findingsOther EKG findings

Prolonged QT syndromeProlonged QT syndrome

www.torsades.orgwww.torsades.org

Diagnostic TestsDiagnostic Tests

Basic laboratory tests Basic laboratory tests

- Leads to specific cause in 2-3% of patients- Leads to specific cause in 2-3% of patients EchocardiogramEchocardiogram Stress testingStress testing Ambulatory monitoring or continuous-loop event monitorAmbulatory monitoring or continuous-loop event monitor Electrophysiologic studiesElectrophysiologic studies Tilt table testingTilt table testing Neurologic testingNeurologic testing Psychiatric evaluationPsychiatric evaluation

EchocardiogramEchocardiogram

May diagnose underlying May diagnose underlying structural heart disease structural heart disease (LV dysfunction, (LV dysfunction, hypertrophic hypertrophic cardiomyopathy, cardiomyopathy, significant aortic stenosis)significant aortic stenosis)

Stress testingStress testing

Frequently obtained Frequently obtained in patients with in patients with cardiac disease cardiac disease

Useful in patients Useful in patients with exertion-related with exertion-related syncope or exercise-syncope or exercise-induced arrhythmiasinduced arrhythmias

Testing for arrhythmiasTesting for arrhythmias

Symptoms occurring with arrhythmias occur in Symptoms occurring with arrhythmias occur in 4% of patients in studies using Holter monitoring.4% of patients in studies using Holter monitoring.

Event recorders require the patient to activate the Event recorders require the patient to activate the unit to have the rhythm stored at the time of unit to have the rhythm stored at the time of symptoms.symptoms.

Intermittent loop recorders can store several Intermittent loop recorders can store several minutes of recording if the unit has the ability.minutes of recording if the unit has the ability.

Event recorders and Holter monitors can be Event recorders and Holter monitors can be ordered via CHCSordered via CHCS

Ordering monitoring devicesOrdering monitoring devices

Ordered in CHCSOrdered in CHCS Under consult procedure to cardiologyUnder consult procedure to cardiology

- Holter or event monitor- Holter or event monitor Specify in consult amount of time for event Specify in consult amount of time for event

monitor (# of weeks)monitor (# of weeks) Make sure you have a correct address on patient Make sure you have a correct address on patient

because event monitor is mailed to them.because event monitor is mailed to them.

Implantable loop recordersImplantable loop recorders

Placed in subcutaneous pocket, usually in left pectoral Placed in subcutaneous pocket, usually in left pectoral regionregion

Can store about 45 minutes of retrospective Can store about 45 minutes of retrospective electrocardiographic recordingelectrocardiographic recording

Can record automatically or be activated by the patient Can record automatically or be activated by the patient after an eventafter an event

Usually reserved for recurrent syncope in whom diagnosis Usually reserved for recurrent syncope in whom diagnosis remains uncertainremains uncertain

Diagnostic yield between 25-40% during a period 8-10 Diagnostic yield between 25-40% during a period 8-10 monthsmonths

Monitoring devicesMonitoring devices

Electrophysiologic studiesElectrophysiologic studies

Yield depends on whether Yield depends on whether there is structural heart disease there is structural heart disease or abnormal findings on EKGor abnormal findings on EKG

Among patients with heart Among patients with heart disease, ~ 21% have inducible disease, ~ 21% have inducible ventricular tachycardia and ventricular tachycardia and 34% have bradycardia (14% 34% have bradycardia (14% with multiple diagnoses)with multiple diagnoses)

In patients with abnormal In patients with abnormal EKG’s, ~ 3% have inducible EKG’s, ~ 3% have inducible ventricular tachycardia and ventricular tachycardia and 19% have bradycardia19% have bradycardia

Poor sensitivy/specificity for Poor sensitivy/specificity for bradyarrhythmiasbradyarrhythmias

Tilt table testingTilt table testing

Used for diagnosis of neurocardiogenic or Used for diagnosis of neurocardiogenic or vasovagal syncopevasovagal syncope

Positive test is one where a hypotensive episode Positive test is one where a hypotensive episode is provoked that reproduces a patient’s symptomsis provoked that reproduces a patient’s symptoms

Specificity of negative test on passive tilt at Specificity of negative test on passive tilt at angles between 60-70 degrees is close to 90%angles between 60-70 degrees is close to 90%

Sensitivity of test is uncertain because of no gold Sensitivity of test is uncertain because of no gold standardstandard

Tilt table test protocolTilt table test protocol

Variety of protocols have been describedVariety of protocols have been described Angle of tilt (60-90 degrees)Angle of tilt (60-90 degrees) Duration of tilt (10-60 minutes)Duration of tilt (10-60 minutes) Patient monitored in supine position for five minutes, then Patient monitored in supine position for five minutes, then

placed in head-up tilt positionplaced in head-up tilt position Second tilt can be performed with isoproterenol infusion Second tilt can be performed with isoproterenol infusion

if patient asymptomatic during first tilt (nitrates are if patient asymptomatic during first tilt (nitrates are another agent used)another agent used)

Carotid massage can be performed with testCarotid massage can be performed with test

Grubb, B. P. N Engl J Med 2005;352:1004-1010

Indications for Tilt-Table Testing

Grubb, B. P. N Engl J Med 2005;352:1004-1010

Indications for Tilt-Table Testing

Grubb, B. P. N Engl J Med 2005;352:1004-1010

Demonstration of the Use of a Tilt Table

Neurologic testingNeurologic testing

EEGEEG- May be helpful to rule out seizures/epilepsy- May be helpful to rule out seizures/epilepsy

- Provides diagnostic information in < 2% of cases of syncope- Provides diagnostic information in < 2% of cases of syncope

Head CT scanHead CT scan MRI MRI Carotid doppler ultrasound Carotid doppler ultrasound CT angiographyCT angiography

Psychiatric evaluationPsychiatric evaluation

Generalized anxiety disorder, panic disorder, and Generalized anxiety disorder, panic disorder, and major depression may cause syncope by major depression may cause syncope by predisposing patients to neurally mediated predisposing patients to neurally mediated reactions.reactions.

Fainting is a known manifestation of somatization Fainting is a known manifestation of somatization disorder.disorder.

Alcohol and drug dependence/abuse may also Alcohol and drug dependence/abuse may also lead to syncope.lead to syncope.

Useful hints on the wardsUseful hints on the wards

Fall precautionsFall precautions

- Protocol: yellow armband, bed alarm, side rails up, offer - Protocol: yellow armband, bed alarm, side rails up, offer toileting q2 while awake/qhs/qAM, frequent reorientation toileting q2 while awake/qhs/qAM, frequent reorientation PRNPRN

Seizure precautionsSeizure precautions Telemetry monitoringTelemetry monitoring

- Speak to in person or call using hotline phones to - Speak to in person or call using hotline phones to telemetry tech for any eventstelemetry tech for any events

- Also a telemetry chart that you can look at- Also a telemetry chart that you can look at

Treatment Treatment

Neurocardiogenic Neurocardiogenic

- Avoidance of predisposing factors- Avoidance of predisposing factors

- Patient should be instructed to lie down at onset of prodromal - Patient should be instructed to lie down at onset of prodromal symptomssymptoms

- Isometric contractions of arm and leg muscles, intense hand gripping- Isometric contractions of arm and leg muscles, intense hand gripping

- Increased fluid and salt intake- Increased fluid and salt intake

- Tilt training (standing for 10-30 minutes each day against a wall)- Tilt training (standing for 10-30 minutes each day against a wall)

- Pharmacologic agents (beta-blockers, fludrocortisone, midodrine, - Pharmacologic agents (beta-blockers, fludrocortisone, midodrine, SSRI’s)SSRI’s)

- Permanent cardiac pacing- Permanent cardiac pacing

TreatmentTreatment

Orthostatic hypotensionOrthostatic hypotension

- Volume replacement in those with intravascular - Volume replacement in those with intravascular volume depletionvolume depletion

- Discontinuing or reducing doses of drugs- Discontinuing or reducing doses of drugs

- In cases of autonomic failure, increasing intake - In cases of autonomic failure, increasing intake of salt and fluid, use of waist-high support of salt and fluid, use of waist-high support stockings and abdominal bindersstockings and abdominal binders

- Fludrocortisone or midodrine- Fludrocortisone or midodrine

TreatmentTreatment

Neurologic causesNeurologic causes

- Antiseizure medications for seizure disorder- Antiseizure medications for seizure disorder

- Surgical intervention for severe carotid artery - Surgical intervention for severe carotid artery diseasedisease

Psychiatric causesPsychiatric causes

- Psychiatric referral- Psychiatric referral

- Medications (antidepressive, anxiolytic)- Medications (antidepressive, anxiolytic)

Treatment for cardiac causesTreatment for cardiac causes

Ventricular arrhythmiasVentricular arrhythmias

- Antiarrhythmic therapy, ICD placement, radiofrequency - Antiarrhythmic therapy, ICD placement, radiofrequency ablation, electrophysiologic guided surgeryablation, electrophysiologic guided surgery

Bradycardia due to conduction abnormalitiesBradycardia due to conduction abnormalities- Pacemaker placement (sinus node dysfunction, high - Pacemaker placement (sinus node dysfunction, high grade AV block,)grade AV block,)

Severe aortic stenosisSevere aortic stenosis- Aortic valve replacment- Aortic valve replacment

Hypertrophic cardiomyopathyHypertrophic cardiomyopathy- Beta blockers or CCB’s, RV pacing, myomectomy, - Beta blockers or CCB’s, RV pacing, myomectomy, mitral valve replacmentmitral valve replacment

Pacemakers/ICDPacemakers/ICD

                                                              

ReferencesReferences

1.1. Kapoor W. N.Kapoor W. N. Primary Care: Syncope Primary Care: Syncope. N Engl J Med 2000; . N Engl J Med 2000; 343:1856 1862, Dec 21, 2000.343:1856 1862, Dec 21, 2000.

2.2. Grubb B. P. Neurocardiogenic Syncope. N Engl J Med 2005; Grubb B. P. Neurocardiogenic Syncope. N Engl J Med 2005; 352:1004-1010, Mar 10, 2005.352:1004-1010, Mar 10, 2005.

3.3. Olshansky B. Evaluation of the patient with syncope. UpToDate Olshansky B. Evaluation of the patient with syncope. UpToDate 2005.2005.

4.4. Olshansky B. Pathogenesis and etiology of syncope. UpToDate Olshansky B. Pathogenesis and etiology of syncope. UpToDate 2005. 2005.

5.5. Olshansky B. Mangement of the patient with syncope. UpToDate Olshansky B. Mangement of the patient with syncope. UpToDate 2005.2005.

6.6. MedStudyMedStudy

Questions?Questions?