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Syncope A Diagnostic and Treatment Strategy

Syncope A Diagnostic and Treatment Strategy. Developed by: David G. Benditt, M.D. Richard Sutton, DScMed University of Minnesota Medical Center Royal Brompton Hospital, London, UK. Presentation Overview. Prevalence & Impact Etiology Diagnosis & Evaluation Options

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Syncope A Diagnostic and Treatment Strategy

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  1. SyncopeA Diagnostic and Treatment Strategy Developed by: David G. Benditt, M.D. Richard Sutton, DScMed University of Minnesota Medical Center Royal Brompton Hospital, London, UK

  2. Presentation Overview • Prevalence & Impact • Etiology • Diagnosis & Evaluation Options • Specific Conditions • Treatment Options • Insights into more efficient and effective diagnosis and treatment of patients with syncope

  3. Section I:Prevalence and Impact

  4. The Significance of Syncope The only difference between syncope and sudden death is that in one you wake up.1 1 Engel GL. Psychologic stress, vasodepressor syncope, and sudden death. Ann Intern Med 1978; 89: 403-412.

  5. The Significance of Syncope 1 National Disease and Therapeutic Index on Syncope and Collapse, ICD-9-CM 780.2, IMS America, 1997 2 Blanc J-J, L’her C, Touiza A, et al. Eur Heart J, 2002; 23: 815-820. 3 Day SC, et al, AM J of Med 1982 4 Kapoor W. Evaluation and outcome of patients with syncope. Medicine 1990;69:160-175

  6. Individuals <18 yrs Military Population 17- 46 yrs Individuals 40-59 yrs* Individuals >70 yrs* 15% 20-25% 16-19% 23% Syncope Reported Frequency *during a 10-year period Brignole M, Alboni P, Benditt DG, et al. Eur Heart J, 2001; 22: 1256-1306.

  7. infrequent, unexplained: 38% to 47% 1-4 explained: 53% to 62% The Significance of Syncope • 500,000 new syncope patients each year 5 • 170,000 have recurrent syncope 6 • 70,000 have recurrent, infrequent, unexplained syncope 1-4 1 Kapoor W, Med. 1990;69:160-175. 2 Silverstein M, et al. JAMA. 1982;248:1185-1189. 3 Martin G, et al. Ann Emerg. Med. 1984;12:499-504. 4 Kapoor W, et al. N Eng J Med. 1983;309:197-204. 5 National Disease and Therapeutic Index, IMS America, Syncope and Collapse #780.2; Jan 1997-Dec 1997. 6 Kapoor W, et al. Am J Med. 1987;83:700-708.

  8. The Significance of Syncope • Some causes of syncope are potentially fatal • Cardiac causes of syncope have the highest mortality rates 1 Day SC, et al. Am J of Med 1982;73:15-23. 2 Kapoor W. Medicine 1990;69:160-175. 3 Silverstein M, Sager D, Mulley A. JAMA. 1982;248:1185-1189. 4 Martin G, Adams S, Martin H. Ann Emerg Med. 1984;13:499-504.

  9. Impact of Syncope 73% 1 71% 2 60% 2 Proportion of Patients 37% 2 Anxiety/Depression Alter DailyActivities RestrictedDriving ChangeEmployment 1Linzer, J Clin Epidemiol, 1991. 2Linzer, J Gen Int Med, 1994.

  10. Section II:Etiology

  11. Syncope:ASymptom…Not a Diagnosis • Self-limited loss of consciousness and postural tone • Relatively rapid onset • Variable warning symptoms • Spontaneous complete recovery

  12. Causes of Syncope1 1Kapoor W. In Grubb B, Olshansky B (eds) Syncope: Mechanisms and Management. Armonk NY; Futura Publishing Co, Inc: 1998; 1-13.

  13. Syncope: Etiology Neurally- Mediated Orthostatic Cardiac Arrhythmia Structural Cardio- Pulmonary Non- Cardio- vascular • 1 • Vasovagal • Carotid Sinus • • Situational • Cough • Post- micturition • 2 • Drug • Induced • • ANS • Failure • Primary • Secondary • 3 • Brady • Sick sinus • AV block • • Tachy • VT • SVT • Long QT Syndrome * • 4 • Aortic Stenosis • HOCM • • Pulmonary • Hypertension • 5 • Psychogenic • • Metabolic • e.g. hyper- • ventilation • Neurological 24% 11% 14% 4% 12% Unknown Cause = 34% DG Benditt, UM Cardiac Arrhythmia Center

  14. Causes of Syncope-like States • Migraine* • Acute hypoxemia* • Hyperventilation* • Somatization disorder (psychogenic syncope) • Acute Intoxication (e.g., alcohol) • Seizures • Hypoglycemia • Sleep disorders * may cause ‘true’ syncope

  15. Section III:Diagnosis and Evaluation Options

  16. Syncope Diagnostic Objectives • Distinguish ‘True’ Syncope from other ‘Loss of Consciousness’ spells: • Seizures • Psychiatric disturbances • Establish the cause of syncope with sufficient certainty to: • Assess prognosis confidently • Initiate effective preventive treatment

  17. Initial Evaluation(Clinic/Emergency Dept.) • Detailed history • Physical examination • 12-lead ECG • Echocardiogram (as available)

  18. Syncope Basic Diagnostic Steps • Detailed History & Physical • Document details of events • Assess frequency, severity • Obtain careful family history • Heart disease present? • Physical exam • ECG: long QT, WPW, conduction system disease • Echo: LV function, valve status, HOCM • Follow a diagnostic plan...

  19. Conventional Diagnostic Methods/Yield 9 Day S, et al. Am J Med. 1982; 73: 15-23. 10 Stetson P, et al. PACE. 1999; 22 (part II): 782. 5 Kapoor, JAMA, 1992 6 Krahn, Circulation, 1995 7 Krahn, Cardiology Clinics, 1997. 8 Eagle K,, et al. The Yale J Biol and Medicine. 1983; 56: 1-8. 1 Kapoor, et al N Eng J Med, 1983. 2 Kapoor, Am J Med, 1991. 3 Linzer, et al. Ann Int. Med, 1997. 4 Kapoor, Medicine, 1990. * Structural Heart Disease †MRI not studied

  20. SyncopeEvaluation and Differential Diagnosis • Complete Description • From patient and observers • Type of Onset • Duration of Attacks • Posture • Associated Symptoms • Sequelae History – What to Look for

  21. 12-Lead ECG • Normal or Abnormal? • Acute MI • Severe Sinus Bradycardia/pause • AV Block • Tachyarrhythmia (SVT, VT) • Preexcitation (WPW), Long QT, Brugada • Short sampling window (approx. 12 sec)

  22. Carotid Sinus Massage • Site: • Carotid arterial pulse just below thyroid cartilage • Method: • Right followed by left, pause between • Massage, NOT occlusion • Duration: 5-10 sec • Posture – supine & erect

  23. Carotid Sinus Massage • Outcome: • 3 sec asystole and/or 50 mmHg fall in systolic blood pressure with reproductionof symptoms = Carotid Sinus Syndrome (CSS) • Contraindications • Carotid bruit, known significant carotid arterial disease, previous CVA, MI last 3 months • Risks • 1 in 5000 massages complicated by TIA

  24. Conventional AECGLow Yield, Poor Symptom / Arrhythmia Concordance* • 8 studies, 2612 patients • 19% pts had symptoms with AECG • Only 4% had arrhythmia with symptoms • 79% pts were without symptoms • 14% had arrhythmia despite absence of symptoms * ACC/AHA Task Force, JACC 1999;912-948

  25. Ambulatory ECG

  26. Head-up Tilt Test (HUT) • Unmasks VVS susceptibility • Reproduces symptoms • Patient learns VVS warning symptoms • Physician is better able to give prognostic / treatment advice

  27. Head-Up Tilt Test (HUT) DG Benditt, UM Cardiac Arrhythmia Center

  28. Electroencephalogram • Not a first line of testing • Syncope from Seizures • Abnormal in the interval between two attacks – Epilepsy • Normal – Syncope

  29. Value of Event Recorder in Syncope *Asterisk denotes event marker Linzer M. Am J Cardiol. 1990;66:214-219.

  30. Reveal® Plus Insertable Loop Recorder Patient Activator Reveal® Plus ILR 9790 Programmer

  31. ILR Recordings* 56 yo woman with syncope accompanied with seizures. Infra-Hisian AV Block: Dual chamber pacemaker 65 yo man with syncope accompanied with brief retrograde amnesia. VT and VF: ICD and meds *Medtronic data on file

  32. Unexplained Syncope after history, physical exam, ECG, Holter Low Risk (EF > 35%) ILR Usual care including: External loop recorder Tilt test, EPS and others - + - + External loop recorder Tilt test, EPS, others Diagnosis ILR Randomized Assessmentof Syncope Trial Krahn A, Klein GJ, Skanes Y. Circulation 2001; 104:46-51.

  33. RAST Methods • Prospective randomized trial • 60 patients with unexplained syncope referred for cardiac investigation • Inclusion: • Recurrent unexplained syncope • Referred to the arrhythmia service for cardiac investigation • No clinical diagnosis after history, physical, ECG and at least 24 hours of cardiac monitoring • Exclusion: • LVEF < 35% • Unable to give informed consent • Major morbidity precluding one year of follow-up Krahn A, Klein GJ, Skanes Y. Circulation 2001; 104:46-51.

  34. ILR n=30 Conventional n=30 RAST Results Unexplained Syncope n=60 In Follow-up n=3 Diagnosed n=14 Undiagnosed n=13 Diagnosed n=6 Undiagnosed n=24 Krahn A, Klein GJ, Skanes Y. Circulation 2001; 104:46-51.

  35. RAST Crossover Results Unexplained Syncope n=60 13/30 Undiagnosed after monitoring 6 accepted crossover to conventional 24/30 Undiagnosed after conventional 21 accepted crossover to ILR Diagnosed n=1 Undiagnosed n=5 Diagnosed n=8 Undiagnosed n=5 In follow-up n=8 Krahn A, Klein GJ, Skanes Y. Circulation 2001; 104:46-51.

  36. RAST - Diagnoses number of patients Krahn A, Klein GJ, Skanes Y. Circulation 2001; 104:46-51.

  37. Conventional EP Testing in Syncope • Limited utility in syncope evaluation • Most useful in patients with structural heart disease • Heart disease……..50-80% • No Heart disease…18-50% • Relatively ineffective for assessing bradyarrhythmias Brignole M, Alboni P, Benditt DG, et al. Eur Heart Journal 2001; 22: 1256-1306.

  38. EP Testing in Syncope:Useful Diagnostic Observations • Inducible monomorphic VT • SNRT > 3000 ms or CSRT > 600 ms • Inducible SVT with hypotension • HV interval ≥ 100 ms (especially in absence of inducible VT) • Pacing induced infra-nodal block

  39. ISSUE Study InternationalStudyofSyncopeof UncertainEtiology • Objectives: • Understand the mechanism of syncope in tilt-positive and tilt-negative (isolated) patients • Use the ILR to assess the correlation of rhythms captured during tilt testing and spontaneous recurrent episodes • Inclusion Criteria: • Patients with three or more syncopal episodes in the last 2 years • Groups matched in age, sex, history of syncope, ECG, Echo abnormalities, SHD and arrhythmias Moya A. Circulation. 2001; 104:1261-1267

  40. 111 syncope patients 3 episodes in 2 years, first and last episode >6 months apart History, physical exam, ECG, CSM, echo, Holter (24 hr), other tests as appropriate Tilt test followed by implant of Reveal Insertable Loop Recorder Follow-up to recurrent spontaneous episode ISSUE Study Design • Multicenter, prospective Moya A. Circulation. 2001; 104:1261-1267

  41. ISSUE Study Results Moya A. Circulation. 2001; 104:1261-1267

  42. ISSUE Study • Conclusions: • Homogeneous findings from tilt-negative and tilt-positive syncope patients were observed (clinical characteristics and outcomes). Most frequent finding was asystole secondary to progressive sinus bradycardia, suggesting a neuromediated origin • In this study tilt-negative patients had as many arrhythmias (18%) as tilt-positive patients (21%) • In tilt-positive patients the spontaneous episode ECG was more frequently asystolic than what was predicted by tilt test Moya A. Circulation. 2001; 104:1261-1267

  43. ISSUE Study Implications • HUT outcome was not predictive of vasodepressor vs. cardioinhibitory response • Bradycardia is common in spontaneous VVS - independent of HUT outcome • Bradycardia is more prevalent in spontaneous events vs. HUT induced VVS • Clinical Implication: Consider a strategy of postponing treatment until a spontaneous episode can be documented Moya A. Circulation. 2001; 104:1261-1267

  44. Symptom-Rhythm Correlation Auto Activation Point Patient Activation Point

  45. Diagnostic Limitations • Difficult to correlate spontaneous events and laboratory findings • Often must settle for an attributable cause • Unknowns remain 20-30% 1 1Kapoor W. In Grubb B, Olshansky B (eds) Syncope: Mechanisms and Management. Armonk NY; Futura Publishing Co, Inc: 1998; 1-13.

  46. Unexplained Syncope Diagnosis History and Physical Exam Surface ECG ENT Evaluation Endocrine Evaluation • CV Syncope Workup • Holter • ELR or ILR • Tilt Table • Echo • EPS • Neurological Testing • Head CT Scan • Carotid Doppler • MRI • Skull Films • Brain Scan • EEG • Other CV Testing • Angiogram • Exercise Test • SAECG Psychological Evaluation Adapted from: W.Kapoor.An overview of the evaluation and management of syncope. From Grubb B, Olshansky B (eds) Syncope: Mechanisms and Management. Armonk, NY: Futura Publishing Co., Inc.1998.

  47. Tilt Holter/ ELR ILR Tilt ILR Typical Cardiovascular Diagnostic Pathway Syncope History and Physical, ECG KnownSHD NoSHD > 30 days; > 2 Events < 30 days Echo EPS - + Tilt/ILR Treat Adapted from: Linzer M, et al. Annals of Int Med, 1997. 127:76-86. Syncope: Mechanisms and Management. Grubb B, Olshansky B (eds) Futura Publishing 1999 Zimetbaum P, Josephson M. Annals of Int Med, 1999. 130:848-856. Krahn A et al. ACC Current Journal Review,1999. Jan/Feb:80-84.

  48. Section IV:Specific Conditions

  49. Neurally-Mediated Reflex Syncope (NMS) • Vasovagal syncope (VVS) • Carotid sinus syndrome (CSS) • Situational syncope • post-micturition • cough • swallow • defecation • blood drawing • etc.

  50. NM Reflex Syncope: Pathophysiology • Multiple triggers • Variable contribution of vasodilatation and bradycardia

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