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Down for the Count! The Evaluation of Syncope

Down for the Count! The Evaluation of Syncope. Wyatt W. Decker, M.D. Department of Emergency Medicine Mayo Clinic and Mayo Medical School. OUTLINE. Case Epidemiology Signs and symptoms What data help to risk-stratify patients with syncope? Who should be admitted after a syncopal event?.

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Down for the Count! The Evaluation of Syncope

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  1. Down for the Count!The Evaluation of Syncope Wyatt W. Decker, M.D. Department of Emergency Medicine Mayo Clinic and Mayo Medical School

  2. OUTLINE • Case • Epidemiology • Signs and symptoms • What data help to risk-stratify patients with syncope? • Who should be admitted after a syncopal event?

  3. Case Presentation 82-year-old male was found by son, unresponsive When ambulance arrived, his pulse was 70 and BP was 160/98

  4. Case Presentation82-Year-Old Male History: HTN on HCTZ Exam: Facial contusion, unable to move (L) wrist ECG: SR, LBBB, PVCs X-ray: (L) wrist fracture

  5. Case Presentation82-Year-Old Male What to do? 1) Holter as outpatient 2) Echo 3 ) Admit for EP studies 4) Admit for 23° monitoring

  6. Case Presentation82-Year-Old Male Risk Stratification 1) High risk for an adverse event 2) Moderate risk 3) Low risk

  7. Case Presentation82-Year-Old Male Question orthostatic blood pressure 1) Always check - very useful 2) Sometimes check - can be useful 3) Never check - is useless

  8. SYNCOPE: Definition • A transient loss of consciousness • Spontaneous and full recovery • Loss of postural tone • No prolonged confusion

  9. “Syncope and sudden death are the same, except that in one you wake up” - Anonymous

  10. SYNCOPE: Epidemiology • 6% hospital admits • Up to 3% ED visits • 12-40% of young adults • 6% incidence in > 75 y/o

  11. SYNCOPE: Natural History Mortality Sudden Death 60 50 40 % 30 20 10 0 1 2 3 4 5 0 1 2 3 4 5 Y ear of follow-up Cardiogenic Undetermined Noncardiac Kapoor: Medicine, 1990

  12. Vasodepressor (1-29%) Situational (1-8%) Seizure Psychogenic Orthostatic (4-12%) Drug-induced (2-9%) Carotid sinus Neuralgia Neurologic (TIA, stroke, migraine) SYNCOPE: Etiology - Noncardiac

  13. B-blocker Nitrates CCB Ace I Phenothiazines; antidepressants Antiarrhythmics Diuretics Digoxin Insulin Drugs of abuse EtoH SYNCOPE: Drug Induced • N = 70; Syncope Clinic• 13% probable drug related

  14. SYNCOPE: Etiology Cardiac • Obstruction to flow (3-11%) • HOCM, AS, MS, myxoma • PS, PE, Pulm HTN • MI, tamponade, AD • Arrhythmias (5-30%) • Sick sinus, AV block, pacer • VT, SVT

  15. Cardiogenic Vasovagal CHS Undetermined Other Age-Dependent Causes of SyncopeMayo Clinic: 1996-1998 (n=1,291) <65 years n=607 65 years n=684 3% 18% 17% 10% 19% 24% 43% 23% 30% 13%

  16. SYNCOPE: Signs/Symptoms • Age • Those less than 45 tend to do well • Those over 65 are higher risk • Ages in between are incremental • There is no age cutoff Kapoor, et al: NEJM 309;1983

  17. SZ vs. syncope N = 94 SZ = 41; No SZ = 53 Logistic Regression Analysis SZ Diagnosis Frothing Tongue biting Disoriented < 45 y/o LOC > 50 min Not a SZ Sweating,nausea prior and oriented after event > 45 y/o SYNCOPE: Signs/Symptoms Hoefnagels, et al: J Neurology 238; 1991

  18. SYNCOPE: Signs/Symptoms • Tongue-biting • 106 SZ patients vs. 45 syncope patients • Sensitivity 24%; specificity 99% • Based on 8 patients withtongue-biting Benbadis, et al: Arch Int Med 155;1995

  19. SYNCOPE: Signs/Symptoms Feature Diagnosis - Postexertional - Structural heart disease - 2 minutes of standing - Orthostatic - Cardiac - No prodrome - Vasovagal - Stress-related - Micturition syncope - Situational

  20. SYNCOPE: Signs/Symptoms • CHF = poor outcome • N = 491; 12% with syncope • Cardiac syncope; 49% dead 1 year • Noncardiac syncope: 39% dead 1 year • No syncope; 12% dead 1 year • Risk factor for poor outcome in multiple studies Middlekauff, et al: JACC 21:1; 1993

  21. Proceed with Caution! SYNCOPE: Signs/Symptoms Orthostatic hypotension • Generally defined as drop in systolic BP> 20 mmHg on standing • Present in 40% patients > 70 years • Present in up to 23% patients < 60 • Reproduction of symptoms may be useful

  22. SYNCOPE: Diagnostic Testing • ECG - diagnostic  2-12% • Blood work - low yield, not helpful • Only lab abnormalities found are those expected based on history/PE • Holter monitoring • Tilt table • Electrophysiology studies Day, et al: Am J Med 73;1982.

  23. SYNCOPE: Evaluation - ECG • What to look for: • VT (3 or more beats) • Sinus pause (> 2 seconds) • Bradycardia with symptoms • SVT with symptoms or hypotension • AF slow vent response • 2° + 3° AV block • Pacemaker malfunction Martin, et al: Ann Emerg Med 29:4; 1997

  24. Diagnostic Efficacy of 24 Hour Holter Monitoring for Syncope 1,512 patients Syncope/presyncope during monitoring (17%) Arrhythmia without symptoms (15%) Documented arrhythmia (2.1%) Gibson: AJC 53, 1984

  25. Tilt Table Testing Positive yield (pseudo Specificity Repro- sensitivity (%) controls (%) duciblity (%) Passive tilt 20-75 80-90 60-70 Isoproterenol 40-85 55-80 65-90

  26. Results of Electrophysiologic Testing in Patients with Syncope of Unknown Cause Patient Abnormal Reference (no.) EP (%) Sra et al 86 34 DiMarco et al 25 68 Gulamhusein et al 34 18 Hess et al 32 56 Akhtar et al 30 53 Olshansky et al 105 37

  27. Diagnostic challenge Initial H&P, ECG non-diagnostic 30-60% ED patients SYNCOPE: The Dilemma Kapoor, et al: NEJM 1983;309:4

  28. Discord in theEvaluation of Syncope Neurologist Cardiologist

  29. SYNCOPE: The Dilemma • Disposition Challenge • Patients often asymptomatic in ED • Majority of causes benign • Concern of sudden death

  30. SYNCOPE: Risk Stratification • Identify low-risk patients who need minimal testing and have a low likelihood of an adverse event • Identify high-risk patients in whom a more aggressive approach towards care is indicated

  31. SYNCOPE: Risk Stratification • Syncope patients in ED • Derivation N = 252 • Validation N = 374 • Data: History, PE, ECG • Outcome: Arrhythmias and mortality at 1 year Martin, et al: Ann Emerg Med 29;1997

  32. SYNCOPERisk Stratification Mortality at 1 Year Died within one year of syncopal episode Strictly defined arrhythmias or diedof a cardiac cause in the 1st year

  33. SYNCOPE: Management • Risk factors: > 45 years, ventricular arrhythmia, abnormal ECG, CHF • Martin, et al • 72° cardiac mortality;0% with no risk factors • 1 year mortality 57% with 3 • 1 year mortality 80% with 4

  34. ACEP Clinical Policy: Syncope 1. What data help risk stratify? Level B: • Over 60 years = high risk • CHF = high risk • Under 45 years = low risk Level C: • PE, c/w cardiac outflow obstruction = high risk • Hx c/w vasodepressor etiology = low risk

  35. ACEP Clinical Policy: Syncope Diagnostic testing Level B: Obtain 12-lead ECG when history, PE indeterminate

  36. ACEP Clinical Policy:Who Should be Admitted Level B: Admit patients with syncope and any of the following: • A history of CHF or ventricular arrhythmias • Associated chest pain or other symptoms compatible with acute coronary syndrome • Evidence of significant CHF or valvular heat disease on PE • ECG findings of ischemia, arrhythmia, prolonged QT interval, or bundle branch block

  37. ACEP Clinical Policy:Admission Level C: Consider admission for patients with syncope and any of the following: • Age older than 60 years • History of coronary artery disease or congenital heart disease • Family history of unexpected sudden death • Exertional syncope in younger patinets without an obvious benign etiology for the syncope

  38. Syncope: Summary • Etiology is often unclear • Risk stratification is key • Admit high risk patients • Intermediate risk? • Low risk: Send out

  39. THANK YOU

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