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Aims. Brief overview Identifying Syncope Identify patients at risk SCD risk of physical injury DVLA regulations. What is dizzy turns, blackouts and palpitations?. Dizzy Turns and Blackouts. Cardiac. Non - Cardiac. Syncope.

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Aims

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  1. Aims • Brief overview • Identifying Syncope • Identify patients at risk • SCD • risk of physical injury • DVLA regulations

  2. What is dizzy turns, blackouts and palpitations?

  3. Dizzy Turns and Blackouts Cardiac Non - Cardiac

  4. Syncope “Transient Global Cerebral Hypoperfusion characterised by rapid onset, short duration and spontaneous complete recovery” (ESC)

  5. 50% 15% ESC 2008 Syncope guidelines

  6. Non - cardiac

  7. Palpitations Cardiac • Tachyarhythmia • AF/flutter / SVT / VT • Ventricular and atrial ectopics Non Cardiac • sinus tachycardia • GORD • Anxiety / emotion • Rare (Phaechromocytoma / carcinoid)

  8. How Common a Problem is it? • 1% ED referrals (40% admission rate) • Common in general population ED 0.7 GP 9 Gen population - 18-39 Syncopal episodes / visits per 1000 pt years (Ganzebaum, J Cardiovasc EP 2006 Netherlands)

  9. Prognosis / Importance 1 Prognosis • Structural HD and Primary electrical disease 2 Recurrence 3 QOL 4 Cost - high (UK £611 per pt / £1080 per diagnosis)

  10. Initial Evaluation • Makes diagnosis in 20 - 50% of cases • Aims - • identify syncope • Risk assess for SCD (/ risk of recurrence and injury / driving)

  11. Initial evaluation, diagnosis and risk stratification • History • Examination (including lying and standing BP) • ECG (Further investigations only make diagnosis in 25% of undiagnosed patients)

  12. Diagnosis of Syncope • “Transient global cerebral hypoperfusion characterised by rapid onset, short duration and spontaneous complete recovery” † Was LOC complete? † Was LOC transient with rapid onset and short duration? † Did the patient recover spontaneously, completely and without sequelae?

  13. ESC 2008 Syncope guidelines

  14. Examination • Evidence of structural heart disease • Murmours • Signs of heart failure • Orthostatic BP

  15. ECG • Q waves (prior MI) • LBBB or RBBB and anterior or posterior hemiblock

  16. ECG • Q waves (prior MI) • LBBB or RBBB and anterior or posterior hemiblock • AV block (2nd degree and higher) • Sinus bradycardia (<50 bpm) or sinus pauses >3 seconds

  17. ECG 2 • Pre-excitation (short PR and delta wave) • Prolonged QT • Widened QRS • RBBB with ST elevation V1 -V3 (Brugada)

  18. Important causes of cardiac syncope - “Red Flags” - Palpitations • Severe SOB • Severe Chest Pain • Syncope / near syncope

  19. ARVD • Fibofatty infiltration of RV

  20. Further Investigations • Echo (? structural heart disease) • Holter (useful for frequent symptoms) • Loop recorders (internal (REVEAL)/ external) • ETT (syncope during or shortly after exercise) • EP studies • Neurological / psychiatric assessment

  21. DVLA Quick Guide

  22. Driving Regulations DVLA Quick Guide

  23. Summary • Common problem • Directed history, examination and ECG can make diagnosis in up to 50% of cases. • Initial Evaluation allows identification of high risk patients for speedy referral / investigations

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