Syncope

1. Syncope

2. Syncope is a common disorder, affecting 30% of adults Syncope is responsible 1% to 6% of emergency department visits 0.6% to 1.0% of hospital admissions Bimodal presentation Peak at early adulthood Neurocardiogenic Late in life degenerative

3. Difficulty in diagnoses Episodes may be sporadic Multiple possible causes

6. Neurocardiogenic syncope Normal reflex Venous pooling Drop in BP Increased symp drive Myocardial C fibres � also affect vagal tone

7. Neurocardiogenic syncope Abnormal reflex Increased venous pooling Increased symp drive Marked pressure effect on C fibres Paradoxical increase in vagal tone Reduces contraction Increases dilatation

8. Diagnostic tests and yields ECG 2-11% Holter Monitoring 2% External Loop Recorder 20% Tilt Table 11-87% EP Study without structural heart disease11% EP Study with structural heart disease 49% Neurological (CT scan, carotid doppler) 0-4%

10. Diagnostic tests and yields ECG 2-11% Holter Monitoring 2% External Loop Recorder 20% Tilt Table 11-87% EP Study without structural heart disease11% EP Study with structural heart disease 49% Neurological (CT scan, carotid doppler) 0-4% Implantable loop recorder 43-88%

11. Syncope increases mortality Study of survival rates with and without syncope Cardiac syncope carried a 6-month mortality rate of greater than 10% Cardiac syncope doubled the risk of death

12. Case 1 64yo male Suddenly felt unwell, strange, dizzy LOC for 2 minutes ECG, Echo, 48hr Holter, Tilt, MRI and sleep deprived EEG all NAD Loop recorder inserted Similar episode 25s pause DDD PM inserted

13. Case 1 He collapsed again several weeks later, while sitting for a meal at a wedding. Repeat EEG Temporal-lobe epilepsy was diagnosed, Treated with oxcarbazepine. He remains asymptomatic at 1 year of follow-up.

14. Case 1 Ictal bradycardia is a rare manifestation of epileptic seizures. There is limited evidence of a preferential left temporal-lobe onset. Most patients are male and >60 years of age This pattern of epilepsy may induce central or obstructive apneas as well as SCD Temporal-lobe epilepsy may present with feelings of panic and impending doom, palpitations, diaphoresis, dyspnea, and paresthesias. Hence, it is easily misdiagnosed as an anxiety attack. The discovery of a major arrhythmia without EEG monitoring may lead to an incorrect diagnosis Cardiac pacemakers may be indicated in symptomatic ictal bradycardia or asymptomatic bradycardia lasting more than 5 seconds.

15. CASE 2 73yo male Under care of diabetic service Referred to cardiology for work-up of black-outs ECG, Echo, 24hr and 7 day holter normal Loop recorder implanted

16. Case 2 After 6 months �will you check this man�s Loop Recorder.........Neurologist reckons he had a 52 second pause on an EEG� �I�d say it�s a typo!....meant 5.2 seconds Loop recorder revealed no patient activated episodes Automatic episodes all later than date of EEG

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22. Case 3 22yo female Referred to Cardiology from Neurology for implantation of loop recorder due to syncope No significant medical Hx Admitted to previous ectasy use, smokes cannabis every day ECG, 7day Holter, Echo NAD MRI, CT, Sleep deprived EEG NAD Loop recorder inserted

23. Case 3 Presented following syncopal episode No awareness of onset When full awareness regained � sitting up in chair Speaks �gibberish� for minutes prior to episode Interrogation revealed

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26. Case 3 Also had one episode of speaking �gibberish� for five minutes, no syncope No associated arrhythmia

27. Case 3 Questions Would you pace this patient now What is the sensitivity/specificity of an EEG in this setting What is the usefulness of repeat EEG