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Syncope

Syncope. David Robertson February 9, 2007. Objectives. Recognize and treat: Severe orthostatic hypotension (AF) Postural tachycardia syndrome (POTS) Neurally mediated syncope (NMS). Cardiovascular Continuum. AF. POTS. NMS. Normotension. Labile HBP. HBP. Bradycardia/hypotension

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Syncope

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  1. Syncope David Robertson February 9, 2007

  2. Objectives • Recognize and treat: • Severe orthostatic hypotension (AF) • Postural tachycardia syndrome (POTS) • Neurally mediated syncope (NMS)

  3. Cardiovascular Continuum AF POTS NMS Normotension Labile HBP HBP Bradycardia/hypotension ~500,000 Americans Orthostatic tachycardia ~500,000 Americans Orthostatic hypotension ~100,000 Americans

  4. Cardiovascular Continuum AF POTS NMS Normotension Labile HBP HBP Bradycardia/hypotension ~500,000 Americans asymptomatic Orthostatic tachycardia symptomatic ~500,000 Americans Orthostatic hypotension ~100,000 Americans

  5. Cardiovascular Continuum AF POTS NMS Normotension Labile HBP HBP Bradycardia/hypotension ~500,000 Americans Orthostatic tachycardia ~500,000 Americans Orthostatic hypotension Severe Dysautonomias ~100,000 Americans

  6. Severe Dysautonomia: Therapy • FIRST LINE: • Water (+40 mmHg!) • Food (-30mmHg!) • SECOND LINE: • Physical Maneuvers • Exercise (in water) • THIRD LINE: • Fludrocortisone + Salt • Pressor Drugs (midodrine)

  7. Cardiovascular Continuum AF POTS NMS Normotension Labile HBP HBP Bradycardia/hypotension ~500,000 Americans Mild Dysautonomias Orthostatic tachycardia ~500,000 Americans Orthostatic hypotension ~100,000 Americans

  8. Postural Tachycardia SyndromePOTS • Upright symptoms without hypotension • Upright tachycardia (>30 bpm rise) • 500,000 Americans: usually young women • Antecedent infection; surgery; pregnancy • Many causes • Tx: low dose (10 mg tid) propranolol

  9. Neuropathic POTS Hyperadrenergic POTS Normal 200 HR (bpm) 50 200 BP(mmHg) 0 60 Tilt Angle 0

  10. Cardiovascular Continuum AF POTS NMS Normotension Labile HBP HBP Bradycardia/hypotension ~500,000 Americans Mild Dysautonomias Orthostatic tachycardia ~500,000 Americans Orthostatic hypotension ~100,000 Americans

  11. Neurally Mediated SyncopeNMS Transient loss of consciousness with loss of postural tone followed by recovery

  12. Syncope Emotional Dysautonomia Viral Swallowing Standing Arrhythmia

  13. Hypotension and Sinus Arrest During Venipuncture 100 BP (mm Hg) 80 60 40 20 ECG 5 10 15 20 25 30 35 40 45 50 0 Time (sec)

  14. Tilt-Induced Bradycardia EKG BP HR Tilt

  15. Syncope: The Problem • Loss of consciousness is common • Long differential diagnosis • Most benign; some fatal • Treatment requires diagnosis

  16. Syncope and its Risk OTHER CAUSES CV DISEASES A cardiac etiology conveys risk Wishwa Kapoor et al.NEJM1983; 309: 197

  17. Why Do We Faint ? Blood/Injury/Fear Pain, blood, medical procedures, fright After minutes or hours of upright posture Generally standing or quiet sitting Worse in heat or warm stuffy rooms Probably related to tilt test syncope Within 30 seconds of arising from sitting or lying Probably increased conductance in muscle bed Can occur with starting to walk after quiet standing At or immediately after peak heavy exercise

  18. Syncope: Common Symptoms Frequent symptoms or signs Nausea Diaphoresis Pallor Fatigue Myoclonic twitches Frequent presyncopal spells Improvement on lying down

  19. Syncope Rate in Young Adults 12-48 % (usually no medical attention)

  20. Syncope • 3-5% of all ER visits (35% admitted) • Syncope 1o diagnosis: 1-6% of admits • 1,000,000 new patients evaluated yearly • Prevalence: 0.7% in young; 6.0% in old • Tends to be young women and old men

  21. Syncope Impact • Recurrent syncope ~ Rheumatoid arthritis • Maybe home schooling • Maybe lose your job • Maybe injury: Falls 4th cause of death • Pacemaker may make you uninsurable

  22. Neurally Mediated Syncope • Recurrent (>3) syncope • No cardiac lesion • Especially in young • Rarely life-threatening • Most gradually improve

  23. Case 1 • 21 year old woman • Syncope during choir practice

  24. No W/U Required • If syncope has an obvious cause • If there is no cause for concern • But if in clinic: H&P plus ECG

  25. The History • Complete Description • Other illnesses (virus?) • Type of Onset • Duration of Attacks • Posture • Associated Symptoms • Sequelae • Prolonged fatigue is almost universal

  26. Case 2 • 21 year old woman • Syncope during basketball competition

  27. Evaluation of Syncope I • Is there structural heart disease ? • Hx • PE • ECG • Echo • Monitoring (loop recorder)

  28. Case 3 • 21 year old woman • Syncope during class • Father died suddenly at 34

  29. Evaluation Of Syncope II • Tilt-Table Test • EP (Electrophysiological) Study • But……only BP, HR during spontaneous syncope is definitive.

  30. Tilt Table Test • Widely used but rarely helpful to patients • Demonstrates what fainting feels like • 20% of normal subjects test positive • Positive test doesn’t mean the patient has NMS • Negative test doesn’t mean patient does not have NMS

  31. Positive Tilt Test • Hemodynamics • Hypotension • Bradycardia • Reproduction of Symptoms • Syncope • Pre-syncope

  32. Normal Subjects Syncope Patients 13 %* 24-75 % Tilt-Table Test: Positivity *but ~30% of normals positive at Vanderbilt MEV PetersenHeart2000; 84: 509

  33. Therapy of Syncope • No drug or device proven helpful • Rate-drop pacemaker • Drugs sometimes employed: • Propranolol • Fludrocortisone • SSRIs • Midodrine • Water?

  34. 16 oz Water: Effect on Tilt Tolerance 45 30 Orthostatic Tolerance (min) 15 0 Water No Water

  35. Vanderbilt University Autonomic Dysfunction Center

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